| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
219 |
167 |
$126K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
962 |
512 |
$123K |
| D1110 |
Prophylaxis - adult |
1,330 |
1,277 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
2,115 |
1,991 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
272 |
166 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
732 |
716 |
$25K |
| D4342 |
|
181 |
80 |
$21K |
| D0274 |
Bitewings - four radiographic images |
693 |
659 |
$20K |
| D2950 |
|
135 |
105 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
392 |
392 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
90 |
63 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,085 |
1,054 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
63 |
62 |
$5K |
| D4910 |
|
12 |
12 |
$784.52 |
| D1120 |
Prophylaxis - child |
25 |
25 |
$747.60 |
| D1208 |
Topical application of fluoride, excluding varnish |
37 |
37 |
$521.25 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$314.25 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$224.56 |