| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
598 |
305 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
305 |
166 |
$16K |
| D1110 |
Prophylaxis - adult |
563 |
561 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
101 |
57 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
442 |
436 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,219 |
1,089 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,029 |
638 |
$6K |
| D0274 |
Bitewings - four radiographic images |
337 |
334 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
137 |
114 |
$3K |
| D2950 |
|
149 |
108 |
$2K |
| D2331 |
|
16 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
293 |
292 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
108 |
108 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$912.47 |
| D1208 |
Topical application of fluoride, excluding varnish |
144 |
144 |
$810.90 |
| D2740 |
Crown - porcelain/ceramic |
126 |
69 |
$0.00 |
| D7880 |
|
12 |
12 |
$0.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$0.00 |
| D4910 |
|
15 |
15 |
$0.00 |