| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,174 |
1,186 |
$209K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,783 |
921 |
$151K |
| D0120 |
Periodic oral evaluation - established patient |
1,594 |
1,583 |
$107K |
| D0350 |
|
10,877 |
2,684 |
$107K |
| D1110 |
Prophylaxis - adult |
1,113 |
1,110 |
$96K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,535 |
1,526 |
$95K |
| D2740 |
Crown - porcelain/ceramic |
194 |
135 |
$92K |
| D4910 |
|
820 |
817 |
$63K |
| D0210 |
Intraoral - complete series of radiographic images |
1,253 |
1,246 |
$58K |
| D1120 |
Prophylaxis - child |
1,258 |
1,249 |
$51K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,307 |
2,196 |
$48K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
577 |
292 |
$45K |
| D1206 |
Topical application of fluoride varnish |
2,210 |
2,198 |
$35K |
| D4341 |
|
472 |
133 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,302 |
1,294 |
$28K |
| D0330 |
Panoramic radiographic image |
588 |
585 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,051 |
942 |
$13K |
| D2954 |
|
87 |
70 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
61 |
28 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
107 |
38 |
$6K |
| D9430 |
|
152 |
143 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
270 |
270 |
$3K |
| D0272 |
Bitewings - two radiographic images |
63 |
63 |
$756.00 |
| D1310 |
|
67 |
67 |
$368.00 |
| D0601 |
|
43 |
43 |
$70.00 |