| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
653 |
351 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
873 |
319 |
$30K |
| D1110 |
Prophylaxis - adult |
645 |
633 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
1,268 |
1,260 |
$15K |
| D0274 |
Bitewings - four radiographic images |
707 |
697 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
554 |
547 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
218 |
138 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
742 |
738 |
$11K |
| D1120 |
Prophylaxis - child |
267 |
267 |
$7K |
| D2740 |
Crown - porcelain/ceramic |
115 |
76 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
919 |
877 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
290 |
209 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
641 |
564 |
$4K |
| D4910 |
|
295 |
292 |
$4K |
| D9920 |
|
34 |
34 |
$2K |
| D0330 |
Panoramic radiographic image |
32 |
32 |
$772.09 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
13 |
$422.11 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
28 |
15 |
$0.00 |
| D2950 |
|
20 |
12 |
$0.00 |