| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,063 |
509 |
$147K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
698 |
318 |
$74K |
| D1110 |
Prophylaxis - adult |
1,417 |
1,364 |
$57K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
323 |
205 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,322 |
1,265 |
$38K |
| D0330 |
Panoramic radiographic image |
698 |
669 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
904 |
867 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,144 |
1,101 |
$25K |
| D2740 |
Crown - porcelain/ceramic |
41 |
37 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
409 |
393 |
$13K |
| D2332 |
|
80 |
45 |
$12K |
| D2330 |
|
103 |
36 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
74 |
25 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
525 |
501 |
$6K |
| D2950 |
|
39 |
35 |
$5K |
| D1206 |
Topical application of fluoride varnish |
213 |
210 |
$3K |
| D4910 |
|
54 |
48 |
$3K |
| D4346 |
|
21 |
18 |
$928.40 |
| D1120 |
Prophylaxis - child |
16 |
16 |
$480.96 |
| D0230 |
Intraoral - periapical each additional radiographic image |
25 |
25 |
$342.13 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
13 |
$156.24 |