| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,980 |
1,379 |
$215K |
| D1110 |
Prophylaxis - adult |
3,789 |
3,789 |
$212K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
256 |
233 |
$174K |
| D0120 |
Periodic oral evaluation - established patient |
4,440 |
4,435 |
$124K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
486 |
384 |
$62K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
853 |
601 |
$57K |
| D1120 |
Prophylaxis - child |
1,144 |
1,144 |
$50K |
| D0272 |
Bitewings - two radiographic images |
2,581 |
2,581 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
551 |
548 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,838 |
1,838 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
775 |
775 |
$23K |
| D2954 |
|
109 |
103 |
$19K |
| D0274 |
Bitewings - four radiographic images |
675 |
675 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,043 |
1,025 |
$14K |
| D0330 |
Panoramic radiographic image |
196 |
196 |
$7K |
| D2330 |
|
52 |
37 |
$3K |
| D2331 |
|
15 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
188 |
188 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
28 |
$370.00 |