| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
443 |
287 |
$59K |
| D2740 |
Crown - porcelain/ceramic |
58 |
26 |
$49K |
| D1110 |
Prophylaxis - adult |
757 |
755 |
$42K |
| D2750 |
|
69 |
58 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
612 |
611 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
426 |
413 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
166 |
43 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
510 |
506 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
137 |
85 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
158 |
157 |
$12K |
| D0330 |
Panoramic radiographic image |
151 |
150 |
$8K |
| D2950 |
|
42 |
37 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
378 |
374 |
$5K |
| D0274 |
Bitewings - four radiographic images |
156 |
156 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
15 |
$4K |
| D1206 |
Topical application of fluoride varnish |
79 |
77 |
$2K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$1K |
| D0270 |
|
12 |
12 |
$162.24 |