| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,947 |
1,807 |
$260K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,567 |
3,550 |
$235K |
| D0120 |
Periodic oral evaluation - established patient |
2,164 |
2,144 |
$148K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,464 |
1,272 |
$131K |
| D0210 |
Intraoral - complete series of radiographic images |
2,697 |
2,682 |
$128K |
| D1120 |
Prophylaxis - child |
2,375 |
2,358 |
$99K |
| D1110 |
Prophylaxis - adult |
976 |
968 |
$85K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,073 |
3,443 |
$77K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
786 |
484 |
$62K |
| D0350 |
|
5,906 |
2,189 |
$60K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
471 |
270 |
$56K |
| D0274 |
Bitewings - four radiographic images |
2,471 |
2,456 |
$52K |
| D1351 |
Sealant - per tooth |
1,464 |
353 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,456 |
3,434 |
$44K |
| D4910 |
|
525 |
525 |
$40K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
52 |
39 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
412 |
177 |
$23K |
| D9430 |
|
665 |
644 |
$21K |
| D4341 |
|
297 |
83 |
$21K |
| D0330 |
Panoramic radiographic image |
358 |
353 |
$11K |
| D0340 |
|
161 |
161 |
$8K |
| D4342 |
|
58 |
18 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
188 |
184 |
$2K |
| D1320 |
|
185 |
185 |
$2K |
| D0272 |
Bitewings - two radiographic images |
136 |
135 |
$2K |
| D1206 |
Topical application of fluoride varnish |
54 |
54 |
$832.50 |
| D1999 |
|
160 |
142 |
$100.00 |
| D1330 |
|
91 |
90 |
$0.00 |
| D1310 |
|
91 |
90 |
$0.00 |
| D0431 |
|
63 |
63 |
$0.00 |