| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,144 |
455 |
$138K |
| D1110 |
Prophylaxis - adult |
1,807 |
1,783 |
$58K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
509 |
209 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
2,039 |
2,018 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,622 |
1,600 |
$28K |
| D0330 |
Panoramic radiographic image |
520 |
513 |
$21K |
| D0274 |
Bitewings - four radiographic images |
1,033 |
1,020 |
$20K |
| D1120 |
Prophylaxis - child |
522 |
518 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
576 |
552 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
659 |
520 |
$5K |
| D0272 |
Bitewings - two radiographic images |
50 |
50 |
$765.70 |
| D0140 |
Limited oral evaluation - problem focused |
41 |
40 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
40 |
25 |
$0.00 |