| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
568 |
432 |
$270K |
| D4910 |
|
1,203 |
1,189 |
$92K |
| D4341 |
|
1,248 |
337 |
$87K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,266 |
1,258 |
$83K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
835 |
452 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
683 |
676 |
$52K |
| D0210 |
Intraoral - complete series of radiographic images |
1,072 |
1,067 |
$51K |
| D2954 |
|
331 |
268 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
608 |
304 |
$33K |
| D1110 |
Prophylaxis - adult |
344 |
341 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,473 |
1,098 |
$26K |
| D1120 |
Prophylaxis - child |
458 |
458 |
$22K |
| D0350 |
|
2,026 |
775 |
$19K |
| D0274 |
Bitewings - four radiographic images |
912 |
902 |
$18K |
| D9430 |
|
276 |
259 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
603 |
602 |
$9K |
| D1206 |
Topical application of fluoride varnish |
460 |
456 |
$7K |
| D4342 |
|
36 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$156.00 |