| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,006 |
559 |
$137K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,070 |
567 |
$113K |
| D2750 |
|
166 |
126 |
$104K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
165 |
123 |
$79K |
| D1110 |
Prophylaxis - adult |
1,594 |
1,582 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
2,653 |
2,638 |
$64K |
| D4342 |
|
559 |
188 |
$55K |
| D4910 |
|
674 |
673 |
$53K |
| D2950 |
|
276 |
209 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,073 |
1,071 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
606 |
595 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
470 |
467 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,277 |
1,236 |
$16K |
| D1206 |
Topical application of fluoride varnish |
592 |
592 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
112 |
111 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
27 |
$6K |
| D0460 |
|
47 |
47 |
$1K |
| D1120 |
Prophylaxis - child |
38 |
38 |
$1K |
| D4346 |
|
25 |
25 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
26 |
$438.12 |