| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
94 |
56 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
1,213 |
1,212 |
$29K |
| D1120 |
Prophylaxis - child |
660 |
659 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
190 |
106 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
969 |
968 |
$20K |
| D2950 |
|
84 |
52 |
$16K |
| D1110 |
Prophylaxis - adult |
296 |
295 |
$14K |
| D0274 |
Bitewings - four radiographic images |
433 |
433 |
$9K |
| D0330 |
Panoramic radiographic image |
130 |
130 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
283 |
278 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
61 |
61 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
185 |
162 |
$2K |