| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
143 |
99 |
$88K |
| D2950 |
|
218 |
155 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
217 |
120 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
931 |
817 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
329 |
307 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
312 |
310 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
177 |
172 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
40 |
$8K |
| D1110 |
Prophylaxis - adult |
134 |
133 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
735 |
397 |
$6K |
| D0274 |
Bitewings - four radiographic images |
166 |
166 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
125 |
125 |
$3K |
| D0330 |
Panoramic radiographic image |
75 |
75 |
$3K |
| D1206 |
Topical application of fluoride varnish |
106 |
106 |
$3K |
| D4342 |
|
39 |
14 |
$3K |
| D1120 |
Prophylaxis - child |
59 |
59 |
$2K |
| D1351 |
Sealant - per tooth |
79 |
18 |
$2K |