| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
294 |
185 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
236 |
150 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
85 |
64 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
322 |
316 |
$12K |
| D1110 |
Prophylaxis - adult |
250 |
247 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
133 |
129 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
90 |
45 |
$9K |
| D2740 |
Crown - porcelain/ceramic |
16 |
15 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
184 |
181 |
$4K |
| D2335 |
|
13 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
57 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
112 |
111 |
$1K |
| D0274 |
Bitewings - four radiographic images |
42 |
42 |
$1K |
| D1120 |
Prophylaxis - child |
14 |
14 |
$390.78 |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
15 |
$264.44 |