| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,013 |
371 |
$166K |
| D1110 |
Prophylaxis - adult |
1,467 |
1,442 |
$93K |
| D2750 |
|
205 |
107 |
$87K |
| D2740 |
Crown - porcelain/ceramic |
125 |
84 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
900 |
881 |
$49K |
| D1206 |
Topical application of fluoride varnish |
1,727 |
1,697 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
797 |
709 |
$36K |
| D3120 |
|
740 |
292 |
$26K |
| D2950 |
|
306 |
178 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
778 |
778 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
399 |
390 |
$22K |
| D0274 |
Bitewings - four radiographic images |
549 |
537 |
$13K |
| D0330 |
Panoramic radiographic image |
272 |
272 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
738 |
688 |
$8K |
| D4341 |
|
70 |
24 |
$5K |
| D4355 |
|
40 |
40 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
282 |
276 |
$3K |
| D1120 |
Prophylaxis - child |
70 |
70 |
$3K |
| D1330 |
|
43 |
43 |
$309.60 |