| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,626 |
941 |
$124K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
785 |
566 |
$75K |
| D1110 |
Prophylaxis - adult |
1,126 |
1,107 |
$42K |
| D2394 |
|
216 |
165 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
323 |
214 |
$27K |
| D0330 |
Panoramic radiographic image |
464 |
439 |
$23K |
| D2740 |
Crown - porcelain/ceramic |
61 |
51 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,228 |
1,212 |
$22K |
| D1120 |
Prophylaxis - child |
655 |
650 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
648 |
610 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
1,049 |
1,034 |
$16K |
| D2950 |
|
115 |
96 |
$12K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
28 |
27 |
$11K |
| D0274 |
Bitewings - four radiographic images |
536 |
529 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
454 |
417 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
91 |
84 |
$821.89 |