| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,319 |
333 |
$95K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
416 |
198 |
$36K |
| D2740 |
Crown - porcelain/ceramic |
46 |
28 |
$30K |
| D1110 |
Prophylaxis - adult |
641 |
633 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
263 |
255 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
420 |
413 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
685 |
674 |
$8K |
| D4342 |
|
88 |
30 |
$4K |
| D0274 |
Bitewings - four radiographic images |
298 |
292 |
$4K |
| D2950 |
|
45 |
27 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
350 |
342 |
$2K |
| D4910 |
|
36 |
36 |
$2K |
| D1206 |
Topical application of fluoride varnish |
78 |
76 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
172 |
149 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
58 |
55 |
$936.12 |