| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,181 |
687 |
$193K |
| D2740 |
Crown - porcelain/ceramic |
246 |
177 |
$188K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
873 |
518 |
$118K |
| D2394 |
|
513 |
334 |
$101K |
| D1110 |
Prophylaxis - adult |
2,101 |
2,077 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
3,229 |
3,203 |
$81K |
| D0220 |
Intraoral - periapical first radiographic image |
4,751 |
4,663 |
$59K |
| D0140 |
Limited oral evaluation - problem focused |
1,500 |
1,484 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,059 |
1,051 |
$44K |
| D4342 |
|
392 |
167 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
444 |
443 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,125 |
1,113 |
$34K |
| D2950 |
|
210 |
152 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,210 |
1,191 |
$27K |
| D4910 |
|
44 |
42 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
33 |
31 |
$664.78 |
| D0270 |
|
39 |
39 |
$509.67 |