| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
402 |
170 |
$224K |
| D1110 |
Prophylaxis - adult |
911 |
854 |
$51K |
| D0274 |
Bitewings - four radiographic images |
688 |
633 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
602 |
570 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
913 |
825 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
257 |
237 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
678 |
621 |
$8K |
| D2954 |
|
55 |
25 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
13 |
$3K |
| D1206 |
Topical application of fluoride varnish |
84 |
80 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
66 |
50 |
$2K |