| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,851 |
881 |
$122K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,964 |
781 |
$105K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
217 |
158 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,319 |
1,310 |
$84K |
| D0210 |
Intraoral - complete series of radiographic images |
1,103 |
1,098 |
$52K |
| D1110 |
Prophylaxis - adult |
624 |
621 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
926 |
919 |
$50K |
| D1120 |
Prophylaxis - child |
906 |
896 |
$33K |
| D9110 |
|
450 |
379 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,409 |
1,686 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,874 |
1,847 |
$23K |
| D4910 |
|
250 |
250 |
$19K |
| D4341 |
|
272 |
70 |
$18K |
| D0350 |
|
2,020 |
788 |
$17K |
| D2954 |
|
146 |
112 |
$15K |
| D1320 |
|
1,073 |
1,032 |
$15K |
| D0274 |
Bitewings - four radiographic images |
385 |
379 |
$8K |
| D9430 |
|
161 |
152 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
458 |
399 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
57 |
41 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
25 |
13 |
$3K |
| D0272 |
Bitewings - two radiographic images |
49 |
49 |
$576.00 |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$450.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$154.00 |
| D0180 |
|
13 |
13 |
$0.00 |
| D1999 |
|
35 |
35 |
$0.00 |