| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,272 |
5,252 |
$233K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,468 |
1,546 |
$165K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
313 |
250 |
$149K |
| D1120 |
Prophylaxis - child |
3,854 |
3,846 |
$148K |
| D0230 |
Intraoral - periapical each additional radiographic image |
30,185 |
5,529 |
$122K |
| D1110 |
Prophylaxis - adult |
1,303 |
1,301 |
$111K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,410 |
858 |
$76K |
| D0274 |
Bitewings - four radiographic images |
3,498 |
3,492 |
$74K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
862 |
861 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,144 |
3,139 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
328 |
229 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
280 |
280 |
$13K |
| D0272 |
Bitewings - two radiographic images |
1,075 |
1,074 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
940 |
938 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
34 |
17 |
$4K |
| D2954 |
|
15 |
12 |
$2K |
| D2331 |
|
19 |
12 |
$2K |
| D2330 |
|
15 |
12 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
14 |
13 |
$940.80 |
| D7111 |
|
17 |
12 |
$861.00 |