| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,045 |
491 |
$140K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
717 |
319 |
$75K |
| D1110 |
Prophylaxis - adult |
935 |
903 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
747 |
716 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
596 |
580 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
781 |
763 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,065 |
1,027 |
$14K |
| D0274 |
Bitewings - four radiographic images |
352 |
346 |
$11K |
| D2740 |
Crown - porcelain/ceramic |
18 |
12 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
137 |
136 |
$9K |
| D1206 |
Topical application of fluoride varnish |
252 |
246 |
$5K |
| D2950 |
|
22 |
13 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
39 |
$1K |
| D1120 |
Prophylaxis - child |
14 |
14 |
$473.16 |