| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,624 |
710 |
$107K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
147 |
100 |
$70K |
| D1110 |
Prophylaxis - adult |
740 |
729 |
$60K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
974 |
955 |
$58K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,069 |
433 |
$57K |
| D0210 |
Intraoral - complete series of radiographic images |
819 |
802 |
$37K |
| D0350 |
|
3,741 |
969 |
$33K |
| D9430 |
|
482 |
447 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
246 |
245 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
151 |
85 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
847 |
843 |
$11K |
| D1120 |
Prophylaxis - child |
283 |
279 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,348 |
903 |
$9K |
| D2954 |
|
83 |
58 |
$9K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
16 |
12 |
$7K |
| D0274 |
Bitewings - four radiographic images |
360 |
359 |
$6K |
| D1320 |
|
88 |
88 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
39 |
$468.00 |
| D1330 |
|
106 |
105 |
$0.00 |
| D1310 |
|
103 |
103 |
$0.00 |