| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
911 |
660 |
$112K |
| D2740 |
Crown - porcelain/ceramic |
107 |
90 |
$71K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
562 |
372 |
$53K |
| D1110 |
Prophylaxis - adult |
702 |
702 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,031 |
1,031 |
$28K |
| D1351 |
Sealant - per tooth |
1,018 |
156 |
$24K |
| D1120 |
Prophylaxis - child |
499 |
497 |
$19K |
| D1206 |
Topical application of fluoride varnish |
987 |
985 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
718 |
690 |
$12K |
| D2950 |
|
61 |
53 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
222 |
219 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
183 |
177 |
$8K |
| D0274 |
Bitewings - four radiographic images |
198 |
198 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
64 |
64 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$375.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$144.00 |