| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
269 |
112 |
$169K |
| D2950 |
|
230 |
99 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
161 |
85 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
302 |
302 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
147 |
145 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
87 |
39 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
448 |
388 |
$7K |
| D4341 |
|
35 |
12 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
103 |
103 |
$3K |
| D1110 |
Prophylaxis - adult |
51 |
51 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
269 |
178 |
$2K |
| D1206 |
Topical application of fluoride varnish |
30 |
30 |
$748.85 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$514.58 |