| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,483 |
797 |
$99K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,443 |
671 |
$78K |
| D1110 |
Prophylaxis - adult |
875 |
874 |
$77K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,129 |
1,129 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
890 |
884 |
$71K |
| D0210 |
Intraoral - complete series of radiographic images |
982 |
982 |
$47K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
57 |
40 |
$27K |
| D1120 |
Prophylaxis - child |
577 |
576 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,062 |
1,181 |
$21K |
| D0274 |
Bitewings - four radiographic images |
895 |
890 |
$18K |
| D1206 |
Topical application of fluoride varnish |
831 |
831 |
$15K |
| D4341 |
|
173 |
55 |
$12K |
| D1320 |
|
771 |
771 |
$11K |
| D4910 |
|
140 |
140 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
548 |
545 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
43 |
29 |
$3K |
| D9430 |
|
53 |
52 |
$2K |
| D2330 |
|
19 |
12 |
$1K |