| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
4,594 |
1,479 |
$167K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,624 |
1,198 |
$56K |
| D1110 |
Prophylaxis - adult |
2,279 |
2,226 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,956 |
1,914 |
$21K |
| D2332 |
|
361 |
149 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,707 |
2,646 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
633 |
282 |
$10K |
| D2330 |
|
383 |
114 |
$10K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
81 |
56 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
3,477 |
3,045 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
275 |
166 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
517 |
318 |
$6K |
| D0160 |
|
523 |
476 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
130 |
65 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
480 |
458 |
$3K |
| D0330 |
Panoramic radiographic image |
315 |
303 |
$3K |
| D0274 |
Bitewings - four radiographic images |
530 |
517 |
$2K |
| D2954 |
|
52 |
30 |
$980.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
51 |
51 |
$160.00 |
| D0171 |
|
36 |
32 |
$150.00 |
| D9310 |
|
12 |
12 |
$88.00 |
| D1120 |
Prophylaxis - child |
24 |
24 |
$28.00 |