| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,587 |
558 |
$162K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,792 |
601 |
$125K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,860 |
493 |
$123K |
| D2740 |
Crown - porcelain/ceramic |
334 |
204 |
$119K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
158 |
138 |
$91K |
| D2950 |
|
655 |
413 |
$49K |
| D1110 |
Prophylaxis - adult |
1,077 |
1,047 |
$36K |
| D0330 |
Panoramic radiographic image |
515 |
436 |
$25K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
179 |
103 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,021 |
895 |
$22K |
| D0274 |
Bitewings - four radiographic images |
974 |
949 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
665 |
665 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,044 |
1,010 |
$7K |
| D7880 |
|
111 |
111 |
$6K |
| D2332 |
|
33 |
12 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
566 |
555 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
146 |
141 |
$3K |
| D1206 |
Topical application of fluoride varnish |
31 |
31 |
$291.06 |
| D4341 |
|
159 |
41 |
$0.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$0.00 |
| D9994 |
|
463 |
463 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
200 |
199 |
$0.00 |
| D2330 |
|
35 |
14 |
$0.00 |