| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,237 |
771 |
$299K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,877 |
596 |
$195K |
| D4342 |
|
1,136 |
410 |
$116K |
| D0210 |
Intraoral - complete series of radiographic images |
601 |
600 |
$50K |
| D2740 |
Crown - porcelain/ceramic |
55 |
28 |
$47K |
| D4910 |
|
526 |
524 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
956 |
951 |
$40K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
201 |
109 |
$33K |
| D2330 |
|
286 |
104 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
514 |
510 |
$14K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
80 |
27 |
$14K |
| D1110 |
Prophylaxis - adult |
96 |
95 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
250 |
248 |
$3K |
| D2950 |
|
23 |
13 |
$3K |
| D1206 |
Topical application of fluoride varnish |
135 |
135 |
$3K |
| D0274 |
Bitewings - four radiographic images |
46 |
46 |
$1K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$999.03 |
| D0230 |
Intraoral - periapical each additional radiographic image |
56 |
56 |
$834.19 |