| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
255 |
143 |
$30K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
196 |
89 |
$24K |
| D1110 |
Prophylaxis - adult |
464 |
462 |
$22K |
| D0330 |
Panoramic radiographic image |
463 |
459 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
515 |
512 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
318 |
305 |
$12K |
| D0274 |
Bitewings - four radiographic images |
355 |
355 |
$9K |
| D2740 |
Crown - porcelain/ceramic |
14 |
12 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
114 |
114 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
147 |
144 |
$2K |
| D1120 |
Prophylaxis - child |
37 |
37 |
$2K |
| D2950 |
|
12 |
12 |
$1K |