| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
825 |
406 |
$49K |
| D2740 |
Crown - porcelain/ceramic |
272 |
167 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
328 |
195 |
$21K |
| D0330 |
Panoramic radiographic image |
277 |
277 |
$18K |
| D1110 |
Prophylaxis - adult |
737 |
722 |
$16K |
| D2950 |
|
331 |
224 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
583 |
575 |
$13K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
65 |
36 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
125 |
87 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
557 |
406 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
524 |
513 |
$2K |
| D1206 |
Topical application of fluoride varnish |
160 |
160 |
$1K |
| D0274 |
Bitewings - four radiographic images |
339 |
337 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
697 |
633 |
$1K |
| D1120 |
Prophylaxis - child |
53 |
53 |
$522.96 |
| D0230 |
Intraoral - periapical each additional radiographic image |
613 |
343 |
$514.28 |
| D0270 |
|
73 |
72 |
$0.00 |
| D4910 |
|
12 |
12 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
123 |
117 |
$0.00 |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
25 |
24 |
$0.00 |