| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,387 |
634 |
$98K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
772 |
387 |
$64K |
| D1110 |
Prophylaxis - adult |
1,689 |
1,596 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,523 |
1,058 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
617 |
280 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,172 |
1,115 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
578 |
544 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
1,088 |
986 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
875 |
844 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,315 |
1,214 |
$15K |
| D2394 |
|
124 |
71 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,001 |
534 |
$11K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
21 |
12 |
$9K |
| D2950 |
|
212 |
78 |
$7K |
| D1120 |
Prophylaxis - child |
142 |
142 |
$6K |
| D2332 |
|
18 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
57 |
57 |
$2K |
| D2331 |
|
17 |
13 |
$1K |