| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,530 |
1,470 |
$440K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,346 |
1,131 |
$225K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
507 |
303 |
$75K |
| D2950 |
|
366 |
275 |
$63K |
| D1120 |
Prophylaxis - child |
1,314 |
1,314 |
$53K |
| D2740 |
Crown - porcelain/ceramic |
64 |
40 |
$45K |
| D1110 |
Prophylaxis - adult |
844 |
844 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,581 |
1,581 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
980 |
980 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,631 |
1,631 |
$40K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
59 |
55 |
$39K |
| D2332 |
|
260 |
153 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
379 |
378 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
1,676 |
1,598 |
$29K |
| D2791 |
|
46 |
39 |
$28K |
| D0274 |
Bitewings - four radiographic images |
575 |
575 |
$21K |
| D4341 |
|
125 |
54 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
442 |
413 |
$18K |
| D2750 |
|
18 |
14 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,064 |
1,027 |
$10K |
| D0272 |
Bitewings - two radiographic images |
206 |
206 |
$5K |
| D2331 |
|
41 |
26 |
$4K |
| D7111 |
|
15 |
12 |
$1K |