| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,401 |
894 |
$121K |
| D1110 |
Prophylaxis - adult |
1,661 |
1,659 |
$83K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
541 |
380 |
$55K |
| D0210 |
Intraoral - complete series of radiographic images |
1,263 |
1,261 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,735 |
1,734 |
$51K |
| D7140 |
Extraction, erupted tooth or exposed root |
485 |
272 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
465 |
268 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,021 |
1,019 |
$26K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
20 |
14 |
$11K |
| D2954 |
|
25 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
85 |
85 |
$2K |
| D2332 |
|
22 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$990.00 |