| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
275 |
138 |
$189K |
| D2950 |
|
277 |
146 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
392 |
179 |
$41K |
| D1110 |
Prophylaxis - adult |
811 |
798 |
$41K |
| D0140 |
Limited oral evaluation - problem focused |
976 |
911 |
$35K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
245 |
124 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
578 |
563 |
$21K |
| D0330 |
Panoramic radiographic image |
502 |
485 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,341 |
1,237 |
$18K |
| D4355 |
|
124 |
124 |
$12K |
| D0274 |
Bitewings - four radiographic images |
558 |
546 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
389 |
387 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
176 |
171 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,681 |
901 |
$10K |
| D2394 |
|
48 |
24 |
$7K |
| D1206 |
Topical application of fluoride varnish |
28 |
28 |
$809.90 |