| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
550 |
266 |
$72K |
| D2740 |
Crown - porcelain/ceramic |
95 |
61 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
635 |
635 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
383 |
383 |
$28K |
| D1110 |
Prophylaxis - adult |
395 |
395 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
109 |
74 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
144 |
83 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
257 |
254 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
577 |
559 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
53 |
30 |
$9K |
| D1120 |
Prophylaxis - child |
176 |
176 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
72 |
42 |
$6K |
| D1351 |
Sealant - per tooth |
214 |
22 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
215 |
215 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
222 |
222 |
$5K |
| D0274 |
Bitewings - four radiographic images |
115 |
115 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
375 |
293 |
$4K |
| D2950 |
|
13 |
12 |
$2K |