| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
244 |
171 |
$169K |
| D1110 |
Prophylaxis - adult |
2,953 |
2,899 |
$158K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,247 |
690 |
$102K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,394 |
731 |
$88K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,518 |
1,459 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
2,615 |
2,580 |
$61K |
| D0210 |
Intraoral - complete series of radiographic images |
862 |
823 |
$61K |
| D0274 |
Bitewings - four radiographic images |
1,163 |
1,153 |
$43K |
| D0140 |
Limited oral evaluation - problem focused |
671 |
644 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
945 |
939 |
$26K |
| D1120 |
Prophylaxis - child |
472 |
470 |
$25K |
| D4342 |
|
246 |
84 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
998 |
962 |
$16K |
| D1351 |
Sealant - per tooth |
124 |
36 |
$5K |
| D3120 |
|
141 |
73 |
$5K |
| D4341 |
|
35 |
13 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
177 |
154 |
$2K |
| D2950 |
|
13 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
13 |
$2K |