| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
551 |
263 |
$76K |
| D1110 |
Prophylaxis - adult |
782 |
778 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
670 |
669 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
272 |
153 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,062 |
1,049 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
562 |
532 |
$27K |
| D0330 |
Panoramic radiographic image |
543 |
542 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
668 |
664 |
$21K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
47 |
29 |
$19K |
| D0274 |
Bitewings - four radiographic images |
648 |
647 |
$16K |
| D1120 |
Prophylaxis - child |
276 |
271 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
780 |
755 |
$9K |
| D4341 |
|
89 |
37 |
$8K |
| D2950 |
|
46 |
29 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
461 |
454 |
$4K |
| D1330 |
|
129 |
128 |
$829.40 |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$475.89 |