| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,562 |
918 |
$212K |
| D0350 |
|
2,430 |
2,072 |
$105K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
982 |
508 |
$104K |
| D1110 |
Prophylaxis - adult |
1,434 |
1,430 |
$66K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
347 |
244 |
$57K |
| D0274 |
Bitewings - four radiographic images |
1,612 |
1,609 |
$48K |
| D2740 |
Crown - porcelain/ceramic |
85 |
66 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,722 |
1,712 |
$41K |
| D0330 |
Panoramic radiographic image |
760 |
758 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
966 |
966 |
$37K |
| D4342 |
|
140 |
67 |
$12K |
| D4910 |
|
136 |
136 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
718 |
709 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
112 |
112 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
79 |
25 |
$6K |
| D2950 |
|
48 |
36 |
$6K |
| D2394 |
|
20 |
12 |
$4K |
| D1206 |
Topical application of fluoride varnish |
178 |
173 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
79 |
79 |
$3K |
| D4346 |
|
14 |
14 |
$643.97 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$279.22 |