| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,793 |
664 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,459 |
681 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
674 |
672 |
$14K |
| D1110 |
Prophylaxis - adult |
1,917 |
1,909 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,608 |
1,601 |
$12K |
| D4341 |
|
453 |
156 |
$11K |
| D2335 |
|
202 |
73 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
234 |
132 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
867 |
858 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
558 |
536 |
$4K |
| D0274 |
Bitewings - four radiographic images |
1,089 |
1,077 |
$2K |
| D1120 |
Prophylaxis - child |
116 |
116 |
$1K |
| D0330 |
Panoramic radiographic image |
958 |
956 |
$1K |
| D2740 |
Crown - porcelain/ceramic |
13 |
12 |
$948.00 |
| D0220 |
Intraoral - periapical first radiographic image |
762 |
746 |
$517.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
631 |
600 |
$270.60 |
| D0603 |
|
30 |
30 |
$240.00 |
| D1206 |
Topical application of fluoride varnish |
31 |
31 |
$187.50 |