| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,973 |
994 |
$100K |
| D1110 |
Prophylaxis - adult |
1,973 |
1,967 |
$61K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
803 |
519 |
$49K |
| D4342 |
|
686 |
199 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,693 |
1,682 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,183 |
1,177 |
$25K |
| D2394 |
|
309 |
226 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
1,416 |
1,409 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
1,052 |
1,011 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
412 |
267 |
$20K |
| D2335 |
|
211 |
111 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
417 |
366 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,848 |
1,876 |
$13K |
| D1206 |
Topical application of fluoride varnish |
911 |
910 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
2,545 |
2,491 |
$11K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
25 |
25 |
$9K |
| D0330 |
Panoramic radiographic image |
224 |
221 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
410 |
400 |
$6K |
| D2332 |
|
83 |
56 |
$5K |
| D4341 |
|
40 |
12 |
$4K |
| D1120 |
Prophylaxis - child |
140 |
135 |
$3K |
| D4910 |
|
65 |
65 |
$2K |
| D0350 |
|
153 |
153 |
$2K |
| D2950 |
|
13 |
12 |
$918.48 |
| D1320 |
|
36 |
36 |
$525.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$100.00 |