| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
818 |
351 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
850 |
844 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
776 |
769 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
708 |
702 |
$31K |
| D1120 |
Prophylaxis - child |
666 |
664 |
$24K |
| D3221 |
|
369 |
239 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,599 |
877 |
$19K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
44 |
27 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
251 |
123 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
196 |
94 |
$11K |
| D0274 |
Bitewings - four radiographic images |
478 |
478 |
$10K |
| D2954 |
|
88 |
52 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
553 |
552 |
$5K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
12 |
$5K |
| D9430 |
|
55 |
51 |
$2K |