| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
764 |
584 |
$58K |
| D1110 |
Prophylaxis - adult |
1,241 |
1,241 |
$54K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
90 |
84 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
356 |
308 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,348 |
1,348 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
468 |
467 |
$19K |
| D0274 |
Bitewings - four radiographic images |
549 |
549 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,055 |
1,050 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
879 |
879 |
$8K |
| D1120 |
Prophylaxis - child |
200 |
200 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
136 |
115 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
364 |
364 |
$4K |
| D0272 |
Bitewings - two radiographic images |
271 |
271 |
$3K |
| D2954 |
|
26 |
26 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
31 |
30 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
155 |
154 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
71 |
71 |
$2K |
| D2331 |
|
22 |
22 |
$2K |
| D1206 |
Topical application of fluoride varnish |
65 |
65 |
$1K |
| D0270 |
|
134 |
134 |
$1K |