| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
893 |
433 |
$122K |
| D1110 |
Prophylaxis - adult |
2,161 |
2,149 |
$98K |
| D2740 |
Crown - porcelain/ceramic |
81 |
32 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,717 |
2,707 |
$64K |
| D0274 |
Bitewings - four radiographic images |
1,430 |
1,423 |
$42K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
225 |
112 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
645 |
642 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
167 |
82 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,288 |
1,269 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,023 |
1,015 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
647 |
639 |
$12K |
| D1120 |
Prophylaxis - child |
365 |
364 |
$12K |
| D4341 |
|
39 |
13 |
$10K |
| D2950 |
|
72 |
30 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
66 |
66 |
$5K |
| D4910 |
|
25 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
36 |
36 |
$743.48 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$603.36 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$393.72 |