| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,189 |
656 |
$132K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,444 |
593 |
$124K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,499 |
1,493 |
$56K |
| D0210 |
Intraoral - complete series of radiographic images |
1,087 |
988 |
$50K |
| D2740 |
Crown - porcelain/ceramic |
54 |
31 |
$37K |
| D1110 |
Prophylaxis - adult |
712 |
711 |
$34K |
| D7140 |
Extraction, erupted tooth or exposed root |
438 |
282 |
$32K |
| D1120 |
Prophylaxis - child |
757 |
756 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
744 |
717 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
904 |
901 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,201 |
1,134 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
127 |
87 |
$16K |
| D4341 |
|
99 |
40 |
$16K |
| D0274 |
Bitewings - four radiographic images |
440 |
439 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,568 |
584 |
$10K |
| D0330 |
Panoramic radiographic image |
173 |
172 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
218 |
217 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
18 |
13 |
$3K |
| D0270 |
|
192 |
191 |
$2K |
| D2950 |
|
12 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
36 |
12 |
$1K |
| D0180 |
|
53 |
53 |
$261.96 |
| D9110 |
|
16 |
15 |
$198.00 |
| D9986 |
|
22 |
20 |
$0.00 |