| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,422 |
606 |
$125K |
| D2740 |
Crown - porcelain/ceramic |
149 |
102 |
$74K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
456 |
247 |
$53K |
| D1110 |
Prophylaxis - adult |
896 |
878 |
$41K |
| D1120 |
Prophylaxis - child |
1,118 |
1,109 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,594 |
1,579 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,596 |
1,583 |
$31K |
| D2950 |
|
247 |
172 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
699 |
682 |
$22K |
| D0274 |
Bitewings - four radiographic images |
775 |
760 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
249 |
118 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,745 |
1,682 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,640 |
1,277 |
$17K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
19 |
17 |
$13K |
| D8670 |
Periodic orthodontic treatment visit |
26 |
26 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
448 |
423 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
595 |
204 |
$8K |
| D0330 |
Panoramic radiographic image |
161 |
153 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
76 |
53 |
$5K |
| D0272 |
Bitewings - two radiographic images |
202 |
202 |
$4K |
| D2394 |
|
30 |
25 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
43 |
40 |
$1K |
| D1351 |
Sealant - per tooth |
39 |
12 |
$1K |