| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,202 |
830 |
$74K |
| D1110 |
Prophylaxis - adult |
1,944 |
1,817 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
789 |
782 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,923 |
1,823 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
914 |
480 |
$23K |
| D2740 |
Crown - porcelain/ceramic |
96 |
78 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
810 |
739 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
431 |
217 |
$10K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
36 |
24 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
647 |
548 |
$8K |
| D0274 |
Bitewings - four radiographic images |
1,795 |
1,643 |
$7K |
| D4341 |
|
297 |
80 |
$6K |
| D2335 |
|
127 |
45 |
$6K |
| D2750 |
|
17 |
14 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
1,224 |
1,021 |
$3K |
| D2952 |
|
42 |
29 |
$2K |
| D1120 |
Prophylaxis - child |
168 |
155 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,007 |
881 |
$2K |
| D3320 |
|
13 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
1,215 |
1,136 |
$2K |
| D0603 |
|
885 |
791 |
$1K |
| D1206 |
Topical application of fluoride varnish |
113 |
100 |
$817.50 |
| D2954 |
|
18 |
14 |
$400.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
13 |
$275.00 |
| D1330 |
|
234 |
206 |
$0.00 |