| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
321 |
228 |
$153K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,417 |
1,403 |
$98K |
| D1110 |
Prophylaxis - adult |
682 |
681 |
$61K |
| D0210 |
Intraoral - complete series of radiographic images |
1,229 |
1,218 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
803 |
799 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
637 |
339 |
$43K |
| D4910 |
|
452 |
451 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,771 |
1,785 |
$37K |
| D1120 |
Prophylaxis - child |
664 |
656 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,387 |
1,380 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,049 |
1,047 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
351 |
208 |
$19K |
| D9430 |
|
529 |
508 |
$17K |
| D0350 |
|
1,376 |
540 |
$14K |
| D4341 |
|
97 |
27 |
$7K |
| D2954 |
|
58 |
50 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
26 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
184 |
177 |
$2K |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$306.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$166.00 |