| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
557 |
181 |
$392K |
| D2950 |
|
438 |
149 |
$59K |
| D0383 |
|
224 |
222 |
$32K |
| D1110 |
Prophylaxis - adult |
241 |
240 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
318 |
317 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
115 |
114 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
380 |
371 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
99 |
99 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
160 |
160 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
42 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$1K |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$239.82 |