| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
226 |
140 |
$149K |
| D2790 |
|
137 |
93 |
$77K |
| D1110 |
Prophylaxis - adult |
1,007 |
1,000 |
$51K |
| D4341 |
|
312 |
122 |
$48K |
| D2950 |
|
163 |
123 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
618 |
595 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
224 |
111 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
675 |
673 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,118 |
833 |
$17K |
| D0330 |
Panoramic radiographic image |
348 |
340 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
370 |
368 |
$14K |
| D0274 |
Bitewings - four radiographic images |
496 |
491 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
142 |
141 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
743 |
379 |
$5K |
| D1351 |
Sealant - per tooth |
147 |
16 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
13 |
$3K |
| D2330 |
|
26 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
14 |
14 |
$529.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$297.00 |