| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
411 |
209 |
$290K |
| D1110 |
Prophylaxis - adult |
1,549 |
1,508 |
$84K |
| D2950 |
|
396 |
209 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
1,089 |
1,075 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
988 |
949 |
$15K |
| D0274 |
Bitewings - four radiographic images |
409 |
402 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
260 |
241 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
113 |
53 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
128 |
40 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
606 |
545 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
178 |
173 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
171 |
165 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
27 |
$2K |
| D0180 |
|
17 |
17 |
$634.00 |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$448.00 |
| D1330 |
|
213 |
204 |
$0.00 |