| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
85 |
40 |
$69K |
| D1110 |
Prophylaxis - adult |
1,499 |
1,479 |
$65K |
| D0274 |
Bitewings - four radiographic images |
1,127 |
1,100 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
368 |
144 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,057 |
1,042 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
344 |
314 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
679 |
659 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,106 |
1,097 |
$20K |
| D2950 |
|
73 |
42 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,271 |
1,231 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
77 |
37 |
$7K |
| D0350 |
|
260 |
258 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
265 |
247 |
$6K |
| D1320 |
|
288 |
281 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
84 |
46 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
205 |
196 |
$4K |
| D0250 |
|
303 |
295 |
$4K |
| D1321 |
|
270 |
264 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
62 |
58 |
$1K |
| D1206 |
Topical application of fluoride varnish |
70 |
70 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$602.16 |