| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
212 |
121 |
$77K |
| D4341 |
|
268 |
95 |
$22K |
| D4910 |
|
350 |
341 |
$19K |
| D1110 |
Prophylaxis - adult |
317 |
308 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
692 |
672 |
$9K |
| D2950 |
|
81 |
47 |
$9K |
| D0274 |
Bitewings - four radiographic images |
412 |
398 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
408 |
394 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
44 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
101 |
95 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
170 |
158 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
173 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
183 |
173 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
16 |
$1K |
| D0330 |
Panoramic radiographic image |
131 |
121 |
$750.65 |