| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
274 |
164 |
$174K |
| D2950 |
|
238 |
143 |
$43K |
| D1110 |
Prophylaxis - adult |
425 |
425 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
554 |
554 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
50 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
679 |
645 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
744 |
377 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
99 |
98 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
28 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
91 |
91 |
$4K |
| D1206 |
Topical application of fluoride varnish |
209 |
209 |
$4K |
| D0330 |
Panoramic radiographic image |
70 |
70 |
$4K |
| D0274 |
Bitewings - four radiographic images |
165 |
165 |
$3K |
| D1120 |
Prophylaxis - child |
43 |
43 |
$2K |