| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,633 |
1,446 |
$195K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,571 |
1,382 |
$171K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,308 |
2,294 |
$139K |
| D0210 |
Intraoral - complete series of radiographic images |
2,121 |
2,107 |
$95K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
191 |
114 |
$90K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
421 |
210 |
$48K |
| D1110 |
Prophylaxis - adult |
548 |
542 |
$47K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
93 |
73 |
$43K |
| D2330 |
|
412 |
222 |
$31K |
| D0350 |
|
2,946 |
1,106 |
$27K |
| D3320 |
|
73 |
55 |
$27K |
| D9430 |
|
743 |
674 |
$24K |
| D4341 |
|
291 |
87 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,064 |
1,055 |
$14K |
| D2954 |
|
118 |
64 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
136 |
97 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,090 |
451 |
$9K |
| D4342 |
|
174 |
56 |
$7K |
| D1120 |
Prophylaxis - child |
179 |
176 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
123 |
121 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
315 |
299 |
$4K |
| D2331 |
|
25 |
14 |
$2K |
| D4910 |
|
20 |
20 |
$2K |
| D1320 |
|
66 |
65 |
$1K |
| D0272 |
Bitewings - two radiographic images |
102 |
97 |
$1K |
| D9110 |
|
13 |
13 |
$756.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$259.20 |
| D1330 |
|
39 |
39 |
$0.00 |