| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
561 |
370 |
$62K |
| D1110 |
Prophylaxis - adult |
1,662 |
1,646 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
717 |
477 |
$53K |
| D0210 |
Intraoral - complete series of radiographic images |
619 |
561 |
$29K |
| D2740 |
Crown - porcelain/ceramic |
53 |
42 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
371 |
120 |
$23K |
| D9630 |
|
1,623 |
1,605 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
713 |
702 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
1,278 |
1,272 |
$16K |
| D2950 |
|
149 |
109 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
241 |
152 |
$15K |
| D0274 |
Bitewings - four radiographic images |
734 |
724 |
$13K |
| D1206 |
Topical application of fluoride varnish |
692 |
684 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
618 |
602 |
$11K |
| D2394 |
|
36 |
26 |
$5K |
| D2332 |
|
34 |
16 |
$4K |
| D1120 |
Prophylaxis - child |
93 |
91 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
468 |
456 |
$3K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
15 |
$0.00 |