| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
381 |
220 |
$311K |
| D0350 |
|
1,191 |
655 |
$230K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
501 |
279 |
$70K |
| D1110 |
Prophylaxis - adult |
763 |
741 |
$64K |
| D2950 |
|
458 |
258 |
$62K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
483 |
254 |
$52K |
| D1354 |
|
658 |
148 |
$35K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
200 |
138 |
$34K |
| D4342 |
|
156 |
64 |
$29K |
| D4910 |
|
122 |
117 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
437 |
426 |
$15K |
| D2394 |
|
73 |
45 |
$14K |
| D0274 |
Bitewings - four radiographic images |
451 |
440 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
188 |
184 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
548 |
531 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
723 |
695 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
125 |
120 |
$9K |
| D2331 |
|
66 |
47 |
$9K |
| D2330 |
|
51 |
32 |
$5K |
| D2332 |
|
30 |
27 |
$5K |
| D2335 |
|
20 |
15 |
$4K |
| D0160 |
|
49 |
49 |
$4K |
| D1206 |
Topical application of fluoride varnish |
87 |
83 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
32 |
31 |
$2K |
| D0272 |
Bitewings - two radiographic images |
39 |
38 |
$886.49 |
| D0460 |
|
28 |
28 |
$781.90 |