| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
244 |
151 |
$160K |
| D1110 |
Prophylaxis - adult |
1,654 |
1,572 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
2,616 |
2,547 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
664 |
328 |
$65K |
| D0274 |
Bitewings - four radiographic images |
1,546 |
1,516 |
$64K |
| D1206 |
Topical application of fluoride varnish |
2,282 |
2,241 |
$58K |
| D1120 |
Prophylaxis - child |
1,153 |
1,131 |
$58K |
| D0220 |
Intraoral - periapical first radiographic image |
2,144 |
2,070 |
$39K |
| D2950 |
|
168 |
119 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,626 |
1,535 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
263 |
250 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
314 |
300 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
115 |
55 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
115 |
107 |
$4K |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$744.00 |
| D1999 |
|
267 |
219 |
$0.00 |