| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
314 |
226 |
$149K |
| D0350 |
|
5,331 |
2,246 |
$84K |
| D1110 |
Prophylaxis - adult |
945 |
943 |
$83K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
966 |
963 |
$63K |
| D0210 |
Intraoral - complete series of radiographic images |
902 |
899 |
$43K |
| D1206 |
Topical application of fluoride varnish |
1,508 |
1,503 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
369 |
167 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
281 |
156 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
187 |
187 |
$14K |
| D0330 |
Panoramic radiographic image |
395 |
394 |
$12K |
| D2954 |
|
53 |
39 |
$6K |
| D0274 |
Bitewings - four radiographic images |
159 |
159 |
$3K |
| D2332 |
|
27 |
12 |
$2K |
| D9430 |
|
51 |
50 |
$2K |
| D1320 |
|
25 |
25 |
$412.50 |