| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
499 |
224 |
$350K |
| D1110 |
Prophylaxis - adult |
605 |
603 |
$35K |
| D2950 |
|
193 |
120 |
$29K |
| D0274 |
Bitewings - four radiographic images |
480 |
478 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
708 |
697 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
429 |
424 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
733 |
655 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
134 |
134 |
$10K |
| D0180 |
|
249 |
249 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
85 |
49 |
$8K |
| D1120 |
Prophylaxis - child |
117 |
117 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
163 |
161 |
$6K |
| D1206 |
Topical application of fluoride varnish |
189 |
189 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
133 |
131 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
27 |
$3K |
| D0272 |
Bitewings - two radiographic images |
31 |
31 |
$982.00 |