| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,575 |
822 |
$282K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,002 |
578 |
$142K |
| D2740 |
Crown - porcelain/ceramic |
166 |
84 |
$129K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,340 |
244 |
$128K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,217 |
525 |
$100K |
| D1110 |
Prophylaxis - adult |
2,089 |
1,921 |
$93K |
| D0210 |
Intraoral - complete series of radiographic images |
981 |
881 |
$88K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,546 |
2,346 |
$84K |
| D0330 |
Panoramic radiographic image |
1,384 |
1,261 |
$61K |
| D1320 |
|
2,570 |
2,353 |
$49K |
| D2332 |
|
384 |
106 |
$45K |
| D1321 |
|
2,105 |
1,922 |
$45K |
| D2950 |
|
251 |
113 |
$35K |
| D2335 |
|
196 |
76 |
$30K |
| D2330 |
|
312 |
121 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
305 |
43 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,236 |
1,094 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
395 |
349 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
343 |
312 |
$9K |
| D5110 |
|
15 |
12 |
$6K |
| D2140 |
|
90 |
55 |
$6K |
| D1206 |
Topical application of fluoride varnish |
249 |
227 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
650 |
572 |
$5K |
| D9243 |
|
35 |
13 |
$2K |
| D9239 |
|
13 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
187 |
95 |
$1K |
| D1120 |
Prophylaxis - child |
15 |
14 |
$300.00 |