| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,845 |
1,001 |
$204K |
| D1351 |
Sealant - per tooth |
6,242 |
1,007 |
$174K |
| D1110 |
Prophylaxis - adult |
2,459 |
2,439 |
$114K |
| D0140 |
Limited oral evaluation - problem focused |
2,424 |
2,248 |
$87K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,762 |
1,751 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
2,383 |
2,374 |
$60K |
| D0210 |
Intraoral - complete series of radiographic images |
1,162 |
1,112 |
$59K |
| D1120 |
Prophylaxis - child |
1,423 |
1,421 |
$55K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
388 |
278 |
$53K |
| D2740 |
Crown - porcelain/ceramic |
81 |
66 |
$50K |
| D1206 |
Topical application of fluoride varnish |
2,006 |
2,002 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,468 |
1,460 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
2,631 |
2,473 |
$38K |
| D2950 |
|
149 |
127 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,354 |
1,423 |
$17K |
| D9110 |
|
246 |
235 |
$16K |
| D4355 |
|
171 |
169 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
136 |
93 |
$11K |
| D4341 |
|
32 |
13 |
$5K |
| D2394 |
|
32 |
25 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
14 |
$2K |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$746.82 |
| D0270 |
|
13 |
12 |
$96.60 |