| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,300 |
1,570 |
$434K |
| D1110 |
Prophylaxis - adult |
3,452 |
3,430 |
$156K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,534 |
759 |
$154K |
| D0120 |
Periodic oral evaluation - established patient |
5,931 |
5,906 |
$142K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
726 |
485 |
$114K |
| D1120 |
Prophylaxis - child |
2,981 |
2,973 |
$102K |
| D1206 |
Topical application of fluoride varnish |
4,224 |
4,198 |
$83K |
| D0220 |
Intraoral - periapical first radiographic image |
4,658 |
4,593 |
$58K |
| D0274 |
Bitewings - four radiographic images |
1,816 |
1,805 |
$54K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,185 |
3,162 |
$49K |
| D0210 |
Intraoral - complete series of radiographic images |
583 |
577 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
686 |
685 |
$29K |
| D2740 |
Crown - porcelain/ceramic |
63 |
41 |
$29K |
| D4910 |
|
340 |
331 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
651 |
643 |
$22K |
| D0180 |
|
502 |
500 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
184 |
67 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
94 |
15 |
$12K |
| D0272 |
Bitewings - two radiographic images |
488 |
488 |
$10K |
| D0350 |
|
235 |
235 |
$7K |
| D2950 |
|
57 |
40 |
$7K |
| D0330 |
Panoramic radiographic image |
40 |
40 |
$2K |
| D1351 |
Sealant - per tooth |
47 |
12 |
$2K |
| D0190 |
|
14 |
14 |
$228.06 |