| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
964 |
512 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
948 |
946 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
844 |
843 |
$62K |
| D1120 |
Prophylaxis - child |
939 |
936 |
$43K |
| D2740 |
Crown - porcelain/ceramic |
87 |
65 |
$41K |
| D1110 |
Prophylaxis - adult |
387 |
385 |
$34K |
| D2394 |
|
330 |
215 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
518 |
517 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,573 |
1,570 |
$21K |
| D9430 |
|
491 |
428 |
$16K |
| D0274 |
Bitewings - four radiographic images |
626 |
622 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,903 |
973 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
89 |
61 |
$7K |
| D0350 |
|
488 |
285 |
$5K |
| D2952 |
|
34 |
29 |
$4K |
| D1351 |
Sealant - per tooth |
140 |
41 |
$3K |
| D2330 |
|
32 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$288.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |