| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
120 |
68 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
126 |
66 |
$13K |
| D2740 |
Crown - porcelain/ceramic |
22 |
12 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
207 |
202 |
$13K |
| D0330 |
Panoramic radiographic image |
162 |
158 |
$12K |
| D1110 |
Prophylaxis - adult |
112 |
111 |
$8K |
| D0274 |
Bitewings - four radiographic images |
133 |
132 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
37 |
12 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
140 |
138 |
$4K |
| D1310 |
|
123 |
121 |
$3K |
| D4355 |
|
27 |
26 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
35 |
34 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
66 |
34 |
$1K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
14 |
$1K |
| D1330 |
|
15 |
13 |
$318.96 |