| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,035 |
2,559 |
$416K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
659 |
531 |
$362K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,878 |
1,336 |
$244K |
| D1120 |
Prophylaxis - child |
4,808 |
4,805 |
$214K |
| D1110 |
Prophylaxis - adult |
4,286 |
4,272 |
$189K |
| D0120 |
Periodic oral evaluation - established patient |
7,471 |
7,468 |
$186K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,253 |
5,253 |
$131K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,238 |
1,240 |
$121K |
| D0140 |
Limited oral evaluation - problem focused |
1,588 |
1,536 |
$71K |
| D0274 |
Bitewings - four radiographic images |
4,570 |
4,564 |
$54K |
| D2954 |
|
555 |
467 |
$53K |
| D0210 |
Intraoral - complete series of radiographic images |
990 |
990 |
$44K |
| D9920 |
|
1,746 |
1,589 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
8,520 |
8,324 |
$42K |
| D1351 |
Sealant - per tooth |
2,138 |
302 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,426 |
1,426 |
$36K |
| D1206 |
Topical application of fluoride varnish |
903 |
900 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,447 |
7,412 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
451 |
269 |
$22K |
| D2394 |
|
223 |
162 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,640 |
1,639 |
$16K |
| D2331 |
|
74 |
53 |
$5K |
| D2332 |
|
38 |
26 |
$3K |
| D0603 |
|
236 |
234 |
$2K |
| D4355 |
|
12 |
12 |
$1K |
| D1353 |
|
101 |
13 |
$1K |
| D0270 |
|
200 |
197 |
$1K |
| D2330 |
|
17 |
12 |
$850.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
29 |
29 |
$715.00 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$640.00 |