| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,233 |
808 |
$87K |
| D1110 |
Prophylaxis - adult |
1,389 |
1,387 |
$64K |
| D1120 |
Prophylaxis - child |
1,367 |
1,367 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
1,851 |
1,851 |
$48K |
| D2740 |
Crown - porcelain/ceramic |
63 |
55 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,335 |
1,335 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
883 |
883 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
461 |
444 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
340 |
264 |
$19K |
| D0274 |
Bitewings - four radiographic images |
1,199 |
1,199 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
130 |
110 |
$11K |
| D2954 |
|
59 |
53 |
$6K |
| D0272 |
Bitewings - two radiographic images |
548 |
548 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
545 |
544 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
94 |
78 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
777 |
775 |
$4K |
| D3221 |
|
41 |
34 |
$2K |
| D1351 |
Sealant - per tooth |
76 |
17 |
$2K |
| D2335 |
|
15 |
12 |
$1K |
| D0270 |
|
102 |
102 |
$525.00 |