| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,055 |
476 |
$70K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
934 |
384 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
765 |
757 |
$50K |
| D1110 |
Prophylaxis - adult |
423 |
423 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
613 |
607 |
$29K |
| D9430 |
|
664 |
604 |
$21K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
35 |
23 |
$17K |
| D0350 |
|
1,282 |
341 |
$12K |
| D4910 |
|
135 |
134 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
76 |
44 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
114 |
114 |
$8K |
| D1320 |
|
416 |
410 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
225 |
225 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
705 |
317 |
$3K |
| D1120 |
Prophylaxis - child |
54 |
53 |
$3K |
| D0274 |
Bitewings - four radiographic images |
118 |
118 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
167 |
158 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$2K |
| D2954 |
|
15 |
13 |
$2K |
| D1330 |
|
61 |
61 |
$0.00 |