| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,554 |
482 |
$111K |
| D2740 |
Crown - porcelain/ceramic |
313 |
212 |
$66K |
| D1110 |
Prophylaxis - adult |
1,207 |
1,176 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
389 |
201 |
$37K |
| D2950 |
|
383 |
270 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
1,314 |
1,283 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
691 |
664 |
$16K |
| D0274 |
Bitewings - four radiographic images |
768 |
748 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
224 |
223 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,285 |
1,139 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
50 |
25 |
$8K |
| D3320 |
|
28 |
24 |
$6K |
| D4342 |
|
92 |
28 |
$6K |
| D4910 |
|
262 |
254 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
716 |
623 |
$5K |
| D4341 |
|
445 |
146 |
$4K |
| D1206 |
Topical application of fluoride varnish |
300 |
298 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
37 |
$951.00 |
| D1120 |
Prophylaxis - child |
70 |
70 |
$566.54 |
| D1354 |
|
182 |
17 |
$0.00 |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$0.00 |