| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
172 |
83 |
$117K |
| D1110 |
Prophylaxis - adult |
1,223 |
1,218 |
$55K |
| D4355 |
|
707 |
703 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,856 |
1,847 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
468 |
316 |
$39K |
| D0220 |
Intraoral - periapical first radiographic image |
2,450 |
2,304 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
958 |
923 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,076 |
1,489 |
$22K |
| D0274 |
Bitewings - four radiographic images |
877 |
873 |
$19K |
| D2950 |
|
93 |
62 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
314 |
311 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
133 |
129 |
$8K |
| D1120 |
Prophylaxis - child |
122 |
122 |
$5K |
| D0330 |
Panoramic radiographic image |
197 |
197 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
42 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
24 |
$3K |
| D1206 |
Topical application of fluoride varnish |
111 |
111 |
$3K |