| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
581 |
330 |
$80K |
| D2740 |
Crown - porcelain/ceramic |
92 |
85 |
$63K |
| D1110 |
Prophylaxis - adult |
1,140 |
1,096 |
$58K |
| D0274 |
Bitewings - four radiographic images |
1,194 |
1,127 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
1,746 |
1,510 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
647 |
601 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
863 |
831 |
$22K |
| D0330 |
Panoramic radiographic image |
340 |
324 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
554 |
501 |
$18K |
| D1206 |
Topical application of fluoride varnish |
595 |
570 |
$12K |
| D9110 |
|
154 |
149 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,171 |
1,050 |
$10K |
| D2950 |
|
56 |
55 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
54 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$3K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$905.35 |