| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
337 |
192 |
$176K |
| D0140 |
Limited oral evaluation - problem focused |
1,259 |
1,188 |
$47K |
| D4355 |
|
456 |
451 |
$42K |
| D1110 |
Prophylaxis - adult |
835 |
831 |
$40K |
| D4341 |
|
292 |
81 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
785 |
776 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
1,690 |
1,557 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
262 |
76 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
199 |
83 |
$22K |
| D2954 |
|
118 |
88 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,097 |
1,442 |
$18K |
| D0274 |
Bitewings - four radiographic images |
601 |
596 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
332 |
299 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
593 |
592 |
$15K |
| D5214 |
|
12 |
12 |
$13K |
| D5213 |
|
12 |
12 |
$13K |
| D1206 |
Topical application of fluoride varnish |
403 |
403 |
$11K |
| D4910 |
|
157 |
156 |
$11K |
| D1120 |
Prophylaxis - child |
212 |
212 |
$9K |
| D1351 |
Sealant - per tooth |
249 |
23 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
71 |
41 |
$7K |
| D0330 |
Panoramic radiographic image |
143 |
141 |
$7K |
| D2950 |
|
41 |
27 |
$4K |
| D2940 |
|
82 |
53 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
18 |
13 |
$3K |