| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
472 |
293 |
$225K |
| D4910 |
|
1,822 |
1,810 |
$140K |
| D1110 |
Prophylaxis - adult |
1,281 |
1,275 |
$114K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,649 |
1,643 |
$108K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,470 |
703 |
$98K |
| D0210 |
Intraoral - complete series of radiographic images |
1,652 |
1,645 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
795 |
788 |
$60K |
| D4341 |
|
750 |
198 |
$52K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
581 |
320 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,009 |
1,994 |
$27K |
| D9430 |
|
644 |
570 |
$21K |
| D0274 |
Bitewings - four radiographic images |
698 |
694 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
120 |
90 |
$9K |
| D1120 |
Prophylaxis - child |
200 |
198 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,706 |
901 |
$7K |
| D4342 |
|
45 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
148 |
138 |
$2K |
| D0350 |
|
104 |
56 |
$988.80 |