| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
396 |
227 |
$286K |
| D1110 |
Prophylaxis - adult |
676 |
673 |
$40K |
| D2954 |
|
208 |
139 |
$40K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
375 |
267 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
284 |
207 |
$26K |
| D2394 |
|
187 |
140 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
609 |
565 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
278 |
167 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
702 |
700 |
$18K |
| D0330 |
Panoramic radiographic image |
247 |
246 |
$18K |
| D2332 |
|
112 |
64 |
$14K |
| D0274 |
Bitewings - four radiographic images |
279 |
277 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
258 |
258 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
486 |
442 |
$7K |
| D1120 |
Prophylaxis - child |
124 |
124 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
92 |
92 |
$4K |
| D9110 |
|
49 |
49 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
12 |
$175.00 |