| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
148 |
86 |
$120K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
355 |
174 |
$49K |
| D1110 |
Prophylaxis - adult |
971 |
934 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
850 |
814 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,176 |
1,145 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
361 |
339 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
603 |
561 |
$22K |
| D2950 |
|
149 |
75 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,419 |
1,346 |
$18K |
| D0274 |
Bitewings - four radiographic images |
461 |
436 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
78 |
42 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
28 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
316 |
293 |
$6K |
| D1206 |
Topical application of fluoride varnish |
225 |
209 |
$5K |
| D4342 |
|
35 |
12 |
$3K |