| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
331 |
200 |
$42K |
| D1110 |
Prophylaxis - adult |
619 |
610 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
389 |
205 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
686 |
670 |
$38K |
| D0330 |
Panoramic radiographic image |
642 |
630 |
$29K |
| D0274 |
Bitewings - four radiographic images |
690 |
675 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,059 |
1,025 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
215 |
209 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
853 |
838 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
178 |
177 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
41 |
12 |
$6K |
| D2740 |
Crown - porcelain/ceramic |
12 |
12 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
164 |
157 |
$4K |
| D4341 |
|
32 |
13 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
38 |
38 |
$981.21 |
| D3120 |
|
40 |
17 |
$980.00 |