| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
54 |
33 |
$37K |
| D1110 |
Prophylaxis - adult |
494 |
483 |
$21K |
| D0330 |
Panoramic radiographic image |
387 |
382 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
469 |
466 |
$14K |
| D2950 |
|
47 |
25 |
$8K |
| D1351 |
Sealant - per tooth |
218 |
27 |
$7K |
| D0274 |
Bitewings - four radiographic images |
585 |
583 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
783 |
766 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
30 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,126 |
632 |
$2K |
| D1120 |
Prophylaxis - child |
15 |
15 |
$608.00 |
| D0120 |
Periodic oral evaluation - established patient |
21 |
21 |
$578.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$420.00 |