| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
223 |
154 |
$152K |
| D1110 |
Prophylaxis - adult |
1,411 |
1,395 |
$75K |
| D2950 |
|
206 |
152 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
396 |
196 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
648 |
633 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
329 |
323 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
725 |
720 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
731 |
713 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
157 |
71 |
$9K |
| D0274 |
Bitewings - four radiographic images |
212 |
208 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
179 |
171 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
438 |
389 |
$6K |
| D1206 |
Topical application of fluoride varnish |
17 |
17 |
$476.00 |