| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
732 |
463 |
$88K |
| D1120 |
Prophylaxis - child |
1,607 |
1,605 |
$61K |
| D1206 |
Topical application of fluoride varnish |
1,962 |
1,960 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,719 |
1,719 |
$45K |
| D2740 |
Crown - porcelain/ceramic |
43 |
25 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
303 |
208 |
$27K |
| D1110 |
Prophylaxis - adult |
476 |
476 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,115 |
1,092 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,463 |
776 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
85 |
58 |
$14K |
| D1351 |
Sealant - per tooth |
473 |
77 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
307 |
307 |
$13K |
| D2950 |
|
70 |
52 |
$12K |
| D0272 |
Bitewings - two radiographic images |
377 |
377 |
$8K |
| D0274 |
Bitewings - four radiographic images |
160 |
160 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
72 |
72 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
53 |
$2K |