| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,324 |
725 |
$92K |
| D1110 |
Prophylaxis - adult |
1,741 |
1,726 |
$75K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,012 |
456 |
$54K |
| D1206 |
Topical application of fluoride varnish |
1,598 |
1,598 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,840 |
1,840 |
$46K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
79 |
69 |
$43K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
440 |
310 |
$37K |
| D1120 |
Prophylaxis - child |
524 |
523 |
$23K |
| D0274 |
Bitewings - four radiographic images |
1,701 |
1,686 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
534 |
520 |
$13K |
| D1351 |
Sealant - per tooth |
626 |
120 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
244 |
244 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
2,195 |
2,175 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,002 |
1,980 |
$10K |
| D0330 |
Panoramic radiographic image |
162 |
162 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
119 |
119 |
$5K |
| D0603 |
|
514 |
514 |
$5K |
| D2954 |
|
17 |
15 |
$2K |
| D1353 |
|
146 |
28 |
$1K |
| D0272 |
Bitewings - two radiographic images |
55 |
55 |
$550.00 |