| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
339 |
236 |
$217K |
| D2950 |
|
332 |
247 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
193 |
107 |
$24K |
| D1110 |
Prophylaxis - adult |
432 |
432 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
263 |
263 |
$12K |
| D0330 |
Panoramic radiographic image |
176 |
176 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
723 |
706 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
259 |
259 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
149 |
148 |
$7K |
| D0274 |
Bitewings - four radiographic images |
353 |
353 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
800 |
413 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
38 |
38 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$691.00 |