| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
320 |
165 |
$31K |
| D1110 |
Prophylaxis - adult |
577 |
543 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
215 |
147 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
726 |
692 |
$27K |
| D1206 |
Topical application of fluoride varnish |
990 |
973 |
$25K |
| D0274 |
Bitewings - four radiographic images |
984 |
940 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
656 |
625 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
321 |
314 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
110 |
49 |
$15K |
| D1120 |
Prophylaxis - child |
336 |
329 |
$14K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
25 |
19 |
$10K |
| D2750 |
|
17 |
12 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
673 |
615 |
$7K |
| D0330 |
Panoramic radiographic image |
90 |
90 |
$4K |
| D1330 |
|
422 |
413 |
$2K |
| D0272 |
Bitewings - two radiographic images |
58 |
57 |
$870.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
58 |
55 |
$636.32 |