| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
115 |
79 |
$80K |
| D2950 |
|
181 |
122 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
294 |
291 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
409 |
407 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
108 |
55 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
54 |
33 |
$9K |
| D1110 |
Prophylaxis - adult |
136 |
136 |
$8K |
| D1120 |
Prophylaxis - child |
60 |
60 |
$2K |
| D1206 |
Topical application of fluoride varnish |
83 |
83 |
$2K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
34 |
34 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
87 |
83 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
37 |
37 |
$1K |