| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
794 |
698 |
$93K |
| D1110 |
Prophylaxis - adult |
1,623 |
1,622 |
$91K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
501 |
439 |
$63K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
464 |
434 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
2,083 |
2,082 |
$59K |
| D0330 |
Panoramic radiographic image |
1,053 |
1,051 |
$34K |
| D0274 |
Bitewings - four radiographic images |
819 |
819 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
146 |
126 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
712 |
707 |
$13K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
14 |
13 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
127 |
117 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
582 |
569 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
501 |
500 |
$7K |
| D1120 |
Prophylaxis - child |
155 |
155 |
$7K |
| D2954 |
|
27 |
25 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
245 |
245 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
230 |
228 |
$3K |
| D2394 |
|
12 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$204.00 |