| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
143 |
98 |
$97K |
| D1110 |
Prophylaxis - adult |
1,841 |
1,718 |
$90K |
| D0120 |
Periodic oral evaluation - established patient |
1,446 |
1,412 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
327 |
191 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
611 |
481 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,143 |
1,014 |
$16K |
| D0274 |
Bitewings - four radiographic images |
498 |
450 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
316 |
130 |
$13K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
12 |
12 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
77 |
77 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
504 |
357 |
$6K |
| D9110 |
|
57 |
57 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
62 |
47 |
$1K |
| D1120 |
Prophylaxis - child |
40 |
27 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
32 |
24 |
$940.00 |
| D1999 |
|
576 |
264 |
$0.00 |