| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,150 |
470 |
$112K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,447 |
466 |
$105K |
| D2740 |
Crown - porcelain/ceramic |
115 |
43 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
854 |
852 |
$21K |
| D1110 |
Prophylaxis - adult |
427 |
426 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,028 |
960 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
268 |
264 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
288 |
268 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
77 |
39 |
$10K |
| D2950 |
|
61 |
26 |
$9K |
| D4355 |
|
99 |
99 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
227 |
226 |
$7K |
| D2954 |
|
32 |
12 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
651 |
425 |
$5K |
| D0274 |
Bitewings - four radiographic images |
98 |
96 |
$3K |
| D2330 |
|
33 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
59 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$1K |
| D1206 |
Topical application of fluoride varnish |
42 |
42 |
$1K |