| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,072 |
505 |
$82K |
| D1110 |
Prophylaxis - adult |
1,230 |
1,218 |
$67K |
| D0210 |
Intraoral - complete series of radiographic images |
801 |
790 |
$60K |
| D2740 |
Crown - porcelain/ceramic |
83 |
57 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,017 |
1,002 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
711 |
375 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
855 |
852 |
$21K |
| D4341 |
|
152 |
51 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
168 |
96 |
$15K |
| D2954 |
|
58 |
43 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
359 |
357 |
$11K |
| D1120 |
Prophylaxis - child |
206 |
204 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
260 |
243 |
$10K |
| D0274 |
Bitewings - four radiographic images |
194 |
193 |
$7K |
| D3120 |
|
205 |
130 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
327 |
314 |
$5K |