| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,480 |
1,109 |
$134K |
| D0120 |
Periodic oral evaluation - established patient |
2,379 |
2,373 |
$134K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,662 |
1,653 |
$105K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,449 |
826 |
$97K |
| D0230 |
Intraoral - periapical each additional radiographic image |
20,976 |
3,509 |
$81K |
| D1120 |
Prophylaxis - child |
2,037 |
2,031 |
$75K |
| D0350 |
|
5,808 |
2,248 |
$58K |
| D1110 |
Prophylaxis - adult |
571 |
571 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
992 |
985 |
$47K |
| D0274 |
Bitewings - four radiographic images |
2,011 |
2,004 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,876 |
2,864 |
$34K |
| D4341 |
|
352 |
97 |
$24K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
44 |
39 |
$21K |
| D4910 |
|
187 |
184 |
$14K |
| D2330 |
|
134 |
69 |
$10K |
| D1351 |
Sealant - per tooth |
440 |
138 |
$9K |
| D9430 |
|
283 |
273 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
525 |
518 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
49 |
24 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
75 |
38 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
38 |
26 |
$3K |
| D0272 |
Bitewings - two radiographic images |
193 |
192 |
$2K |
| D2140 |
|
24 |
12 |
$1K |