| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,479 |
767 |
$98K |
| D1110 |
Prophylaxis - adult |
863 |
862 |
$72K |
| D2740 |
Crown - porcelain/ceramic |
128 |
90 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,153 |
1,151 |
$59K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,886 |
2,257 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
513 |
263 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
389 |
389 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,738 |
1,732 |
$22K |
| D4910 |
|
263 |
263 |
$20K |
| D0274 |
Bitewings - four radiographic images |
808 |
807 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
306 |
306 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
156 |
101 |
$12K |
| D0350 |
|
1,189 |
559 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
820 |
751 |
$10K |
| D1120 |
Prophylaxis - child |
269 |
268 |
$8K |
| D4341 |
|
36 |
12 |
$3K |
| D9430 |
|
31 |
30 |
$992.00 |
| D9110 |
|
15 |
13 |
$693.00 |
| D1999 |
|
43 |
37 |
$46.00 |