| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,258 |
571 |
$132K |
| D2160 |
|
1,346 |
233 |
$110K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,303 |
397 |
$89K |
| D1110 |
Prophylaxis - adult |
2,238 |
2,238 |
$79K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,344 |
512 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
2,698 |
2,698 |
$49K |
| D0210 |
Intraoral - complete series of radiographic images |
764 |
764 |
$39K |
| D1120 |
Prophylaxis - child |
1,226 |
1,224 |
$38K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
549 |
203 |
$37K |
| D2140 |
|
602 |
174 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
769 |
769 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
915 |
915 |
$16K |
| D0274 |
Bitewings - four radiographic images |
886 |
886 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,901 |
1,806 |
$13K |
| D2161 |
|
119 |
32 |
$12K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
19 |
14 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
381 |
356 |
$8K |
| D0272 |
Bitewings - two radiographic images |
630 |
630 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,029 |
1,016 |
$4K |
| D2954 |
|
17 |
14 |
$2K |
| D0602 |
|
174 |
174 |
$2K |
| D1206 |
Topical application of fluoride varnish |
72 |
72 |
$1K |
| D1999 |
|
25 |
25 |
$0.00 |