| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
806 |
517 |
$98K |
| D1110 |
Prophylaxis - adult |
1,077 |
1,076 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
1,788 |
1,782 |
$49K |
| D1120 |
Prophylaxis - child |
951 |
947 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,124 |
1,122 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
368 |
261 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
1,653 |
1,629 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,082 |
1,078 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,403 |
1,324 |
$23K |
| D2740 |
Crown - porcelain/ceramic |
24 |
14 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
325 |
325 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
52 |
39 |
$9K |
| D0330 |
Panoramic radiographic image |
59 |
59 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
84 |
83 |
$4K |
| D1206 |
Topical application of fluoride varnish |
118 |
118 |
$3K |
| D2331 |
|
17 |
13 |
$2K |