| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,303 |
2,445 |
$434K |
| D1110 |
Prophylaxis - adult |
3,889 |
3,885 |
$198K |
| D0120 |
Periodic oral evaluation - established patient |
5,222 |
5,214 |
$149K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,389 |
897 |
$95K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
731 |
535 |
$85K |
| D0272 |
Bitewings - two radiographic images |
3,553 |
3,541 |
$77K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,614 |
3,611 |
$73K |
| D1120 |
Prophylaxis - child |
2,021 |
2,016 |
$70K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
473 |
466 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,122 |
1,090 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
42 |
33 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
97 |
95 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
146 |
111 |
$1K |
| D7111 |
|
18 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$969.85 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$782.21 |