| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,777 |
763 |
$108K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,300 |
639 |
$94K |
| D1110 |
Prophylaxis - adult |
1,275 |
1,239 |
$54K |
| D1206 |
Topical application of fluoride varnish |
1,590 |
1,554 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,361 |
1,319 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,065 |
1,039 |
$31K |
| D0330 |
Panoramic radiographic image |
964 |
935 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
815 |
794 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
2,094 |
1,835 |
$15K |
| D2740 |
Crown - porcelain/ceramic |
21 |
16 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,974 |
1,523 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
113 |
79 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
260 |
254 |
$5K |
| D2331 |
|
60 |
41 |
$4K |
| D2330 |
|
34 |
24 |
$2K |
| D4355 |
|
42 |
40 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$511.90 |
| D2950 |
|
15 |
13 |
$133.07 |
| D3120 |
|
24 |
16 |
$0.00 |