| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,301 |
952 |
$155K |
| D1110 |
Prophylaxis - adult |
1,931 |
1,926 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
3,379 |
3,376 |
$91K |
| D1120 |
Prophylaxis - child |
2,195 |
2,193 |
$87K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
531 |
438 |
$47K |
| D1206 |
Topical application of fluoride varnish |
1,558 |
1,557 |
$38K |
| D2740 |
Crown - porcelain/ceramic |
48 |
39 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
806 |
805 |
$19K |
| D0274 |
Bitewings - four radiographic images |
497 |
497 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
348 |
347 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
748 |
726 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
234 |
230 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
134 |
70 |
$10K |
| D0330 |
Panoramic radiographic image |
128 |
128 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
40 |
$7K |
| D0272 |
Bitewings - two radiographic images |
236 |
236 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
104 |
75 |
$927.75 |