| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,003 |
515 |
$133K |
| D1110 |
Prophylaxis - adult |
2,629 |
2,620 |
$119K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
968 |
439 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
2,070 |
2,064 |
$49K |
| D2740 |
Crown - porcelain/ceramic |
49 |
27 |
$41K |
| D0210 |
Intraoral - complete series of radiographic images |
537 |
535 |
$38K |
| D0180 |
|
753 |
748 |
$31K |
| D0274 |
Bitewings - four radiographic images |
946 |
942 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
140 |
91 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
859 |
846 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
281 |
277 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
141 |
137 |
$6K |
| D1206 |
Topical application of fluoride varnish |
293 |
292 |
$5K |
| D2950 |
|
31 |
15 |
$4K |
| D1120 |
Prophylaxis - child |
103 |
101 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
24 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$253.56 |