| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
602 |
325 |
$80K |
| D1110 |
Prophylaxis - adult |
1,685 |
1,675 |
$75K |
| D0220 |
Intraoral - periapical first radiographic image |
4,668 |
4,543 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,206 |
1,194 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,813 |
1,798 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,151 |
1,147 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,384 |
2,352 |
$34K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
137 |
89 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
505 |
497 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
153 |
152 |
$12K |
| D2740 |
Crown - porcelain/ceramic |
18 |
12 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
48 |
12 |
$5K |
| D4342 |
|
33 |
12 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
14 |
$2K |
| D1206 |
Topical application of fluoride varnish |
41 |
41 |
$673.14 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$357.12 |