| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,495 |
518 |
$100K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,422 |
429 |
$77K |
| D2740 |
Crown - porcelain/ceramic |
114 |
61 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
756 |
750 |
$48K |
| D9430 |
|
1,417 |
1,085 |
$45K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
59 |
31 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
410 |
408 |
$27K |
| D1110 |
Prophylaxis - adult |
311 |
309 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
470 |
467 |
$22K |
| D0350 |
|
1,905 |
437 |
$18K |
| D1120 |
Prophylaxis - child |
302 |
302 |
$14K |
| D4910 |
|
168 |
168 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
149 |
80 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,633 |
788 |
$10K |
| D0330 |
Panoramic radiographic image |
561 |
557 |
$10K |
| D1206 |
Topical application of fluoride varnish |
552 |
549 |
$9K |
| D4341 |
|
113 |
30 |
$8K |
| D0274 |
Bitewings - four radiographic images |
327 |
327 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
341 |
283 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
194 |
194 |
$2K |
| D9210 |
|
38 |
30 |
$756.00 |
| D0270 |
|
12 |
12 |
$60.00 |