| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,537 |
963 |
$104K |
| D1110 |
Prophylaxis - adult |
2,153 |
2,151 |
$95K |
| D1206 |
Topical application of fluoride varnish |
1,834 |
1,832 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
2,000 |
1,998 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
822 |
521 |
$44K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
322 |
243 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
489 |
489 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,448 |
1,446 |
$16K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
39 |
29 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
421 |
421 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
271 |
269 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,839 |
1,829 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,590 |
1,581 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
272 |
272 |
$6K |
| D0330 |
Panoramic radiographic image |
93 |
93 |
$3K |
| D1120 |
Prophylaxis - child |
50 |
50 |
$2K |
| D8670 |
Periodic orthodontic treatment visit |
15 |
15 |
$1K |
| D0603 |
|
109 |
108 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$120.00 |