| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,368 |
703 |
$75K |
| D1110 |
Prophylaxis - adult |
1,883 |
1,866 |
$62K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,199 |
3,175 |
$55K |
| D1120 |
Prophylaxis - child |
1,869 |
1,855 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,129 |
600 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
2,764 |
2,746 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,550 |
1,537 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,081 |
1,067 |
$23K |
| D8670 |
Periodic orthodontic treatment visit |
88 |
82 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
967 |
925 |
$11K |
| D0330 |
Panoramic radiographic image |
403 |
396 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
631 |
586 |
$2K |
| D0340 |
|
108 |
108 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
68 |
68 |
$2K |
| D9920 |
|
12 |
12 |
$822.00 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$602.55 |
| D0230 |
Intraoral - periapical each additional radiographic image |
210 |
124 |
$516.46 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
30 |
25 |
$0.00 |
| D4341 |
|
86 |
27 |
$0.00 |
| D2950 |
|
14 |
12 |
$0.00 |