| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
59 |
46 |
$38K |
| D1110 |
Prophylaxis - adult |
493 |
492 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
629 |
629 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
125 |
63 |
$15K |
| D1120 |
Prophylaxis - child |
240 |
240 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
124 |
121 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
161 |
160 |
$7K |
| D0274 |
Bitewings - four radiographic images |
176 |
175 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
322 |
318 |
$5K |
| D1206 |
Topical application of fluoride varnish |
183 |
181 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
103 |
102 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
364 |
192 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
109 |
109 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
16 |
$2K |