| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,468 |
875 |
$147K |
| D1110 |
Prophylaxis - adult |
2,774 |
2,764 |
$120K |
| D2740 |
Crown - porcelain/ceramic |
216 |
157 |
$116K |
| D0120 |
Periodic oral evaluation - established patient |
3,543 |
3,531 |
$84K |
| D0210 |
Intraoral - complete series of radiographic images |
1,585 |
1,574 |
$78K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,711 |
1,706 |
$54K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
349 |
230 |
$46K |
| D1120 |
Prophylaxis - child |
1,065 |
1,065 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,550 |
1,543 |
$42K |
| D0140 |
Limited oral evaluation - problem focused |
1,152 |
1,132 |
$35K |
| D4341 |
|
238 |
83 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,373 |
1,371 |
$33K |
| D2950 |
|
130 |
110 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
153 |
109 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,036 |
1,015 |
$12K |
| D0330 |
Panoramic radiographic image |
218 |
218 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
195 |
112 |
$10K |
| D4910 |
|
86 |
85 |
$6K |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$480.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
44 |
28 |
$171.15 |