| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
416 |
186 |
$278K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
872 |
429 |
$119K |
| D2950 |
|
447 |
202 |
$59K |
| D0350 |
|
349 |
334 |
$48K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
220 |
123 |
$36K |
| D1110 |
Prophylaxis - adult |
565 |
564 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,067 |
1,061 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
452 |
452 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
227 |
137 |
$24K |
| D4910 |
|
223 |
221 |
$21K |
| D1206 |
Topical application of fluoride varnish |
622 |
620 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,300 |
1,285 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
975 |
968 |
$17K |
| D1120 |
Prophylaxis - child |
373 |
373 |
$17K |
| D0274 |
Bitewings - four radiographic images |
533 |
532 |
$17K |
| D2332 |
|
99 |
57 |
$15K |
| D4341 |
|
66 |
27 |
$13K |
| D2335 |
|
65 |
36 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
143 |
143 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
216 |
215 |
$9K |
| D2394 |
|
22 |
14 |
$5K |
| D0272 |
Bitewings - two radiographic images |
129 |
129 |
$3K |
| D1351 |
Sealant - per tooth |
34 |
12 |
$2K |