| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,609 |
1,361 |
$310K |
| D2740 |
Crown - porcelain/ceramic |
161 |
113 |
$105K |
| D1120 |
Prophylaxis - child |
2,571 |
2,569 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
2,468 |
2,466 |
$65K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,959 |
2,445 |
$62K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
416 |
264 |
$59K |
| D1206 |
Topical application of fluoride varnish |
2,440 |
2,440 |
$59K |
| D1110 |
Prophylaxis - adult |
980 |
978 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,063 |
1,061 |
$46K |
| D0220 |
Intraoral - periapical first radiographic image |
2,601 |
2,566 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
571 |
567 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
431 |
269 |
$38K |
| D2950 |
|
159 |
121 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
763 |
761 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
323 |
319 |
$15K |
| D0274 |
Bitewings - four radiographic images |
458 |
457 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
87 |
62 |
$8K |
| D1351 |
Sealant - per tooth |
45 |
17 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$325.44 |