| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
527 |
278 |
$61K |
| D2740 |
Crown - porcelain/ceramic |
113 |
85 |
$60K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,071 |
1,063 |
$35K |
| D1110 |
Prophylaxis - adult |
897 |
890 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
1,785 |
1,646 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
446 |
433 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
223 |
114 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
570 |
548 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
569 |
567 |
$13K |
| D0330 |
Panoramic radiographic image |
219 |
218 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,531 |
893 |
$11K |
| D0274 |
Bitewings - four radiographic images |
383 |
380 |
$10K |
| D2950 |
|
64 |
45 |
$10K |
| D1206 |
Topical application of fluoride varnish |
336 |
336 |
$9K |
| D1351 |
Sealant - per tooth |
232 |
25 |
$7K |
| D1120 |
Prophylaxis - child |
127 |
127 |
$5K |
| D4341 |
|
24 |
12 |
$2K |