| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
277 |
171 |
$132K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,082 |
450 |
$72K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
984 |
319 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
796 |
785 |
$53K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,630 |
1,635 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,253 |
1,242 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
273 |
269 |
$21K |
| D1110 |
Prophylaxis - adult |
225 |
221 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,090 |
1,079 |
$18K |
| D9430 |
|
459 |
410 |
$15K |
| D1120 |
Prophylaxis - child |
248 |
240 |
$12K |
| D1320 |
|
643 |
637 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
81 |
55 |
$6K |
| D4341 |
|
42 |
12 |
$3K |
| D4910 |
|
39 |
39 |
$3K |
| D0330 |
Panoramic radiographic image |
81 |
81 |
$2K |
| D2330 |
|
23 |
12 |
$2K |