| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
503 |
300 |
$342K |
| D2950 |
|
630 |
354 |
$104K |
| D1110 |
Prophylaxis - adult |
1,530 |
1,528 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
2,351 |
2,348 |
$61K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
358 |
217 |
$50K |
| D1120 |
Prophylaxis - child |
1,138 |
1,135 |
$43K |
| D1206 |
Topical application of fluoride varnish |
1,423 |
1,420 |
$34K |
| D4341 |
|
178 |
70 |
$26K |
| D0274 |
Bitewings - four radiographic images |
646 |
646 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,140 |
1,133 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
411 |
408 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
111 |
68 |
$13K |
| D0330 |
Panoramic radiographic image |
210 |
210 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
139 |
138 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
968 |
874 |
$9K |
| D2394 |
|
43 |
24 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
40 |
$2K |