| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
79 |
54 |
$53K |
| D2950 |
|
138 |
102 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
208 |
109 |
$25K |
| D1110 |
Prophylaxis - adult |
405 |
405 |
$22K |
| D1120 |
Prophylaxis - child |
462 |
462 |
$18K |
| D1206 |
Topical application of fluoride varnish |
578 |
578 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
444 |
444 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
254 |
254 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
555 |
547 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
907 |
444 |
$9K |
| D0274 |
Bitewings - four radiographic images |
93 |
93 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
43 |
43 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
27 |
$1K |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$591.50 |