| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,367 |
1,360 |
$88K |
| D1110 |
Prophylaxis - adult |
4,370 |
4,335 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
3,575 |
3,546 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,991 |
1,971 |
$45K |
| D0274 |
Bitewings - four radiographic images |
3,758 |
3,721 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
794 |
790 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
4,843 |
4,773 |
$17K |
| D1120 |
Prophylaxis - child |
962 |
951 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,217 |
4,556 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
865 |
855 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
238 |
154 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
130 |
95 |
$5K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
15 |
12 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
101 |
98 |
$1K |
| D2954 |
|
13 |
12 |
$585.00 |