| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,285 |
425 |
$40K |
| D2740 |
Crown - porcelain/ceramic |
59 |
37 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
666 |
505 |
$12K |
| D1110 |
Prophylaxis - adult |
646 |
492 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
326 |
151 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
437 |
334 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
469 |
360 |
$7K |
| D1120 |
Prophylaxis - child |
340 |
268 |
$5K |
| D0330 |
Panoramic radiographic image |
322 |
255 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
184 |
65 |
$4K |
| D0274 |
Bitewings - four radiographic images |
724 |
563 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
505 |
418 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
849 |
631 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
92 |
62 |
$2K |
| D0603 |
|
619 |
541 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
743 |
437 |
$1K |
| D2950 |
|
31 |
16 |
$968.00 |
| D2954 |
|
24 |
12 |
$837.00 |
| D0190 |
|
620 |
540 |
$575.00 |
| D0272 |
Bitewings - two radiographic images |
88 |
45 |
$190.00 |
| D9110 |
|
14 |
13 |
$90.00 |
| D9910 |
|
14 |
13 |
$45.00 |
| D1203 |
|
117 |
103 |
$0.00 |
| D9430 |
|
14 |
13 |
$0.00 |
| D1204 |
|
191 |
163 |
$0.00 |
| D9630 |
|
14 |
13 |
$0.00 |
| D1330 |
|
724 |
590 |
$0.00 |