| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
860 |
539 |
$77K |
| D1110 |
Prophylaxis - adult |
1,810 |
1,802 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
1,541 |
1,528 |
$37K |
| D2740 |
Crown - porcelain/ceramic |
43 |
28 |
$32K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
230 |
150 |
$24K |
| D0274 |
Bitewings - four radiographic images |
888 |
882 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
498 |
495 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
260 |
169 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,403 |
1,371 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,866 |
927 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
324 |
315 |
$10K |
| D0330 |
Panoramic radiographic image |
175 |
174 |
$8K |
| D1206 |
Topical application of fluoride varnish |
256 |
253 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
149 |
125 |
$6K |
| D1120 |
Prophylaxis - child |
145 |
142 |
$6K |
| D2950 |
|
18 |
13 |
$3K |