| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
385 |
178 |
$238K |
| D1110 |
Prophylaxis - adult |
2,120 |
1,936 |
$107K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
805 |
399 |
$57K |
| D2950 |
|
304 |
164 |
$46K |
| D0210 |
Intraoral - complete series of radiographic images |
621 |
528 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,112 |
971 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,501 |
1,341 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
772 |
674 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
232 |
228 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
134 |
128 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
209 |
206 |
$3K |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$360.00 |