| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,328 |
636 |
$179K |
| D1110 |
Prophylaxis - adult |
2,695 |
2,676 |
$114K |
| D0120 |
Periodic oral evaluation - established patient |
2,861 |
2,834 |
$66K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
553 |
298 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,345 |
1,334 |
$52K |
| D0274 |
Bitewings - four radiographic images |
1,592 |
1,581 |
$47K |
| D0210 |
Intraoral - complete series of radiographic images |
615 |
611 |
$43K |
| D2740 |
Crown - porcelain/ceramic |
42 |
16 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
157 |
111 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,401 |
1,365 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
352 |
350 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
113 |
54 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
264 |
254 |
$6K |
| D2950 |
|
38 |
26 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
23 |
12 |
$4K |
| D4342 |
|
32 |
13 |
$3K |
| D1206 |
Topical application of fluoride varnish |
95 |
95 |
$2K |
| D4346 |
|
12 |
12 |
$537.44 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$469.29 |