| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
636 |
280 |
$51K |
| D1110 |
Prophylaxis - adult |
1,080 |
951 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
533 |
166 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,037 |
915 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,083 |
947 |
$23K |
| D2740 |
Crown - porcelain/ceramic |
30 |
18 |
$21K |
| D9110 |
|
350 |
319 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
922 |
770 |
$11K |
| D1206 |
Topical application of fluoride varnish |
359 |
343 |
$9K |
| D1120 |
Prophylaxis - child |
142 |
138 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
783 |
338 |
$6K |
| D0330 |
Panoramic radiographic image |
111 |
95 |
$6K |
| D2950 |
|
23 |
18 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
105 |
77 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$786.00 |
| D0270 |
|
13 |
12 |
$171.00 |