| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
856 |
470 |
$583K |
| D1110 |
Prophylaxis - adult |
1,791 |
1,719 |
$93K |
| D2950 |
|
591 |
331 |
$91K |
| D0210 |
Intraoral - complete series of radiographic images |
455 |
436 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,366 |
1,322 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
497 |
471 |
$20K |
| D0274 |
Bitewings - four radiographic images |
464 |
443 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
323 |
307 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
819 |
759 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
124 |
79 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
172 |
168 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
25 |
$4K |
| D2954 |
|
17 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
159 |
131 |
$2K |
| D0330 |
Panoramic radiographic image |
14 |
13 |
$945.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$715.00 |
| D0270 |
|
14 |
13 |
$171.00 |