| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
488 |
203 |
$47K |
| D0210 |
Intraoral - complete series of radiographic images |
358 |
320 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
531 |
502 |
$17K |
| D1120 |
Prophylaxis - child |
368 |
367 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
385 |
337 |
$10K |
| D4355 |
|
149 |
126 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
69 |
46 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
275 |
272 |
$7K |
| D1110 |
Prophylaxis - adult |
151 |
146 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
469 |
425 |
$5K |
| D1206 |
Topical application of fluoride varnish |
143 |
143 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
98 |
97 |
$2K |
| D2740 |
Crown - porcelain/ceramic |
16 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
48 |
14 |
$1K |
| D0274 |
Bitewings - four radiographic images |
39 |
37 |
$896.45 |
| D0230 |
Intraoral - periapical each additional radiographic image |
66 |
49 |
$518.51 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$314.03 |