| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
807 |
455 |
$46K |
| D1110 |
Prophylaxis - adult |
1,106 |
1,082 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
655 |
379 |
$25K |
| D1206 |
Topical application of fluoride varnish |
1,140 |
1,117 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
1,165 |
1,146 |
$12K |
| D1120 |
Prophylaxis - child |
576 |
567 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
343 |
330 |
$8K |
| D0274 |
Bitewings - four radiographic images |
463 |
454 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
123 |
118 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
141 |
129 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
94 |
89 |
$595.73 |
| D2740 |
Crown - porcelain/ceramic |
24 |
14 |
$0.00 |
| D2950 |
|
16 |
13 |
$0.00 |