| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,241 |
2,009 |
$212K |
| D1110 |
Prophylaxis - adult |
1,692 |
1,683 |
$141K |
| D0120 |
Periodic oral evaluation - established patient |
2,354 |
2,337 |
$130K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,908 |
1,897 |
$119K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,497 |
1,096 |
$117K |
| D1120 |
Prophylaxis - child |
2,214 |
2,204 |
$91K |
| D1206 |
Topical application of fluoride varnish |
4,247 |
4,221 |
$59K |
| D2740 |
Crown - porcelain/ceramic |
111 |
92 |
$52K |
| D0274 |
Bitewings - four radiographic images |
1,899 |
1,891 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,366 |
3,791 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
563 |
560 |
$26K |
| D9430 |
|
573 |
551 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
284 |
173 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
987 |
945 |
$12K |
| D4910 |
|
91 |
85 |
$7K |
| D2330 |
|
48 |
25 |
$4K |
| D4341 |
|
52 |
17 |
$4K |
| D2394 |
|
17 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
95 |
95 |
$1K |
| D1351 |
Sealant - per tooth |
42 |
12 |
$826.40 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$270.00 |