| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
356 |
174 |
$246K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
157 |
78 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
196 |
110 |
$24K |
| D2950 |
|
151 |
78 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
465 |
440 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
215 |
96 |
$20K |
| D4910 |
|
175 |
175 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
684 |
599 |
$12K |
| D4341 |
|
43 |
14 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
535 |
269 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
103 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
52 |
52 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
83 |
83 |
$2K |
| D1120 |
Prophylaxis - child |
54 |
54 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
74 |
74 |
$2K |
| D1206 |
Topical application of fluoride varnish |
60 |
60 |
$2K |
| D1351 |
Sealant - per tooth |
46 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$500.50 |