| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
13 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
2,089 |
2,011 |
$1K |
| D1110 |
Prophylaxis - adult |
822 |
786 |
$1K |
| D0274 |
Bitewings - four radiographic images |
1,351 |
1,314 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
183 |
177 |
$872.75 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,227 |
1,210 |
$627.11 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,520 |
1,482 |
$594.48 |
| D0120 |
Periodic oral evaluation - established patient |
1,143 |
1,121 |
$525.56 |
| D2950 |
|
16 |
12 |
$416.32 |
| D1120 |
Prophylaxis - child |
172 |
168 |
$409.80 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$350.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
13 |
$337.08 |
| D0270 |
|
95 |
89 |
$142.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
108 |
102 |
$106.34 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$42.66 |
| D0330 |
Panoramic radiographic image |
43 |
43 |
$0.00 |
| D0601 |
|
305 |
288 |
$0.00 |