| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
551 |
270 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
383 |
194 |
$35K |
| D1110 |
Prophylaxis - adult |
846 |
829 |
$35K |
| D1206 |
Topical application of fluoride varnish |
866 |
849 |
$17K |
| D0274 |
Bitewings - four radiographic images |
533 |
518 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
729 |
719 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
681 |
580 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,237 |
1,080 |
$10K |
| D3120 |
|
626 |
271 |
$8K |
| D2394 |
|
59 |
30 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
794 |
599 |
$7K |
| D2740 |
Crown - porcelain/ceramic |
19 |
12 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
196 |
191 |
$6K |
| D0330 |
Panoramic radiographic image |
134 |
132 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
14 |
$3K |
| D2950 |
|
20 |
14 |
$1K |
| D1120 |
Prophylaxis - child |
14 |
14 |
$335.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$207.90 |