| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
543 |
213 |
$344K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
137 |
58 |
$74K |
| D1110 |
Prophylaxis - adult |
1,297 |
1,172 |
$62K |
| D2954 |
|
247 |
108 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,017 |
915 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,015 |
893 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,706 |
976 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,228 |
1,079 |
$17K |
| D2950 |
|
98 |
42 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
380 |
360 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
194 |
181 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
55 |
27 |
$5K |
| D4341 |
|
42 |
14 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
29 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
70 |
66 |
$3K |
| D3120 |
|
38 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$302.00 |