| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
57 |
38 |
$47K |
| D1110 |
Prophylaxis - adult |
1,494 |
1,410 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
856 |
475 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
885 |
838 |
$22K |
| D0330 |
Panoramic radiographic image |
406 |
380 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
978 |
930 |
$16K |
| D0274 |
Bitewings - four radiographic images |
968 |
928 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
178 |
112 |
$9K |
| D1120 |
Prophylaxis - child |
363 |
351 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
448 |
407 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
133 |
81 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
78 |
55 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,041 |
934 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
318 |
295 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
622 |
334 |
$3K |
| D2160 |
|
41 |
30 |
$3K |
| D1206 |
Topical application of fluoride varnish |
85 |
85 |
$1K |
| D2140 |
|
24 |
14 |
$960.00 |
| D0272 |
Bitewings - two radiographic images |
53 |
45 |
$410.00 |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
12 |
$400.00 |