| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
281 |
101 |
$236K |
| D2950 |
|
275 |
101 |
$37K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
111 |
65 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
283 |
281 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
88 |
59 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
83 |
82 |
$7K |
| D1110 |
Prophylaxis - adult |
47 |
47 |
$4K |
| D1206 |
Topical application of fluoride varnish |
74 |
73 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
122 |
119 |
$2K |
| D4910 |
|
19 |
19 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
50 |
50 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$903.38 |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$833.25 |