| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
414 |
266 |
$196K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,909 |
761 |
$127K |
| D1110 |
Prophylaxis - adult |
1,532 |
1,513 |
$125K |
| D0120 |
Periodic oral evaluation - established patient |
1,870 |
1,838 |
$101K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,148 |
525 |
$91K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,276 |
1,261 |
$79K |
| D0210 |
Intraoral - complete series of radiographic images |
1,599 |
1,580 |
$73K |
| D0350 |
|
4,247 |
1,116 |
$40K |
| D9110 |
|
611 |
480 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,658 |
2,609 |
$33K |
| D2954 |
|
287 |
187 |
$30K |
| D1120 |
Prophylaxis - child |
817 |
790 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,707 |
1,439 |
$27K |
| D9430 |
|
688 |
596 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,022 |
1,006 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
617 |
532 |
$7K |
| D4910 |
|
66 |
66 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
74 |
39 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
22 |
12 |
$3K |
| D1351 |
Sealant - per tooth |
72 |
15 |
$2K |