| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
539 |
245 |
$335K |
| D2950 |
|
615 |
317 |
$103K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
836 |
383 |
$98K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
376 |
211 |
$52K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
515 |
199 |
$47K |
| D1351 |
Sealant - per tooth |
1,011 |
146 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
615 |
611 |
$26K |
| D1110 |
Prophylaxis - adult |
487 |
483 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
368 |
363 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
339 |
333 |
$13K |
| D1206 |
Topical application of fluoride varnish |
353 |
349 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
306 |
304 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
496 |
477 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
107 |
71 |
$8K |
| D1120 |
Prophylaxis - child |
136 |
134 |
$6K |
| D0274 |
Bitewings - four radiographic images |
94 |
93 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
177 |
119 |
$2K |
| D4910 |
|
12 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$324.03 |