| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
820 |
359 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
599 |
598 |
$39K |
| D2740 |
Crown - porcelain/ceramic |
77 |
49 |
$37K |
| D1110 |
Prophylaxis - adult |
345 |
343 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
570 |
569 |
$27K |
| D1351 |
Sealant - per tooth |
406 |
75 |
$15K |
| D1120 |
Prophylaxis - child |
194 |
194 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
92 |
58 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
97 |
63 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
463 |
462 |
$7K |
| D2332 |
|
60 |
34 |
$5K |
| D3320 |
|
13 |
12 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
52 |
51 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$982.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
195 |
55 |
$789.75 |
| D0272 |
Bitewings - two radiographic images |
53 |
53 |
$636.00 |
| D0350 |
|
58 |
32 |
$537.60 |