| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
170 |
62 |
$117K |
| D1110 |
Prophylaxis - adult |
1,384 |
1,329 |
$72K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
497 |
132 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,323 |
1,276 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
2,302 |
1,355 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,415 |
1,044 |
$25K |
| D9110 |
|
441 |
368 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
148 |
143 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
92 |
40 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
163 |
150 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$434.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
13 |
$104.00 |