| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4355 |
|
2,902 |
2,900 |
$212K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,706 |
1,291 |
$175K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,144 |
968 |
$130K |
| D0120 |
Periodic oral evaluation - established patient |
5,474 |
5,457 |
$120K |
| D1110 |
Prophylaxis - adult |
2,673 |
2,666 |
$112K |
| D2740 |
Crown - porcelain/ceramic |
136 |
84 |
$94K |
| D0274 |
Bitewings - four radiographic images |
3,226 |
3,221 |
$83K |
| D0220 |
Intraoral - periapical first radiographic image |
7,099 |
6,662 |
$82K |
| D2790 |
|
135 |
117 |
$81K |
| D0140 |
Limited oral evaluation - problem focused |
2,846 |
2,742 |
$80K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,103 |
4,905 |
$68K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
834 |
575 |
$64K |
| D2394 |
|
300 |
276 |
$41K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
251 |
124 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
644 |
644 |
$26K |
| D0330 |
Panoramic radiographic image |
596 |
596 |
$25K |
| D1120 |
Prophylaxis - child |
384 |
384 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
604 |
604 |
$15K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
14 |
12 |
$8K |
| D4341 |
|
46 |
16 |
$7K |
| D2950 |
|
27 |
24 |
$4K |
| D2335 |
|
44 |
30 |
$3K |
| D0240 |
|
55 |
28 |
$1K |
| D2940 |
|
13 |
12 |
$929.24 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$846.83 |