| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,125 |
2,258 |
$278K |
| D1110 |
Prophylaxis - adult |
4,995 |
4,994 |
$253K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,314 |
1,777 |
$248K |
| D2394 |
|
1,336 |
1,068 |
$189K |
| D0120 |
Periodic oral evaluation - established patient |
6,893 |
6,890 |
$181K |
| D0210 |
Intraoral - complete series of radiographic images |
1,697 |
1,696 |
$75K |
| D0274 |
Bitewings - four radiographic images |
2,572 |
2,572 |
$69K |
| D1120 |
Prophylaxis - child |
1,608 |
1,608 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,174 |
1,174 |
$35K |
| D2335 |
|
196 |
150 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
618 |
501 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,336 |
2,336 |
$33K |
| D2332 |
|
162 |
118 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,179 |
1,176 |
$14K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
25 |
16 |
$14K |
| D0330 |
Panoramic radiographic image |
288 |
288 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
185 |
185 |
$3K |
| D0272 |
Bitewings - two radiographic images |
127 |
127 |
$2K |
| D1351 |
Sealant - per tooth |
36 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
27 |
25 |
$222.38 |