| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
313 |
139 |
$42K |
| D2740 |
Crown - porcelain/ceramic |
84 |
76 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
188 |
83 |
$20K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
140 |
75 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
123 |
67 |
$19K |
| D1110 |
Prophylaxis - adult |
301 |
299 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
221 |
219 |
$8K |
| D0274 |
Bitewings - four radiographic images |
279 |
278 |
$8K |
| D2950 |
|
69 |
63 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
85 |
24 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
257 |
257 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
329 |
323 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
118 |
115 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
223 |
218 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
64 |
62 |
$1K |
| D1206 |
Topical application of fluoride varnish |
85 |
85 |
$1K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$833.28 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$764.32 |