| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
435 |
216 |
$297K |
| D2950 |
|
395 |
208 |
$61K |
| D1110 |
Prophylaxis - adult |
893 |
849 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
702 |
660 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
580 |
553 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
226 |
216 |
$8K |
| D0274 |
Bitewings - four radiographic images |
210 |
205 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
343 |
323 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
37 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
18 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
12 |
$444.00 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$420.00 |