| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
137 |
103 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
693 |
689 |
$45K |
| D9430 |
|
1,287 |
1,100 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
381 |
377 |
$30K |
| D1110 |
Prophylaxis - adult |
309 |
307 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
476 |
221 |
$26K |
| D4910 |
|
339 |
338 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
294 |
163 |
$19K |
| D1120 |
Prophylaxis - child |
330 |
330 |
$17K |
| D2954 |
|
152 |
112 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
253 |
253 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
539 |
537 |
$8K |
| D2330 |
|
82 |
45 |
$7K |
| D0274 |
Bitewings - four radiographic images |
274 |
274 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
348 |
334 |
$4K |
| D1351 |
Sealant - per tooth |
102 |
25 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
556 |
300 |
$2K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$480.00 |