| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
915 |
523 |
$72K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,024 |
1,018 |
$67K |
| D1110 |
Prophylaxis - adult |
717 |
714 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
754 |
428 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
791 |
786 |
$38K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
67 |
55 |
$32K |
| D9430 |
|
989 |
877 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
211 |
211 |
$18K |
| D1206 |
Topical application of fluoride varnish |
974 |
969 |
$16K |
| D4910 |
|
217 |
217 |
$16K |
| D0350 |
|
529 |
429 |
$15K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
91 |
48 |
$11K |
| D1120 |
Prophylaxis - child |
180 |
180 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,682 |
1,015 |
$8K |
| D4341 |
|
73 |
27 |
$5K |
| D0274 |
Bitewings - four radiographic images |
212 |
212 |
$4K |
| D0330 |
Panoramic radiographic image |
118 |
118 |
$3K |
| D2330 |
|
25 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
24 |
$2K |
| D2394 |
|
19 |
17 |
$2K |
| D0270 |
|
153 |
151 |
$765.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$348.50 |
| D0220 |
Intraoral - periapical first radiographic image |
22 |
20 |
$264.00 |