| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
128 |
67 |
$88K |
| D1110 |
Prophylaxis - adult |
470 |
447 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
326 |
310 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
511 |
481 |
$21K |
| D2950 |
|
136 |
70 |
$21K |
| D0330 |
Panoramic radiographic image |
342 |
326 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
366 |
348 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
126 |
59 |
$11K |
| D0274 |
Bitewings - four radiographic images |
288 |
270 |
$9K |
| D1206 |
Topical application of fluoride varnish |
331 |
312 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
558 |
496 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
181 |
175 |
$4K |
| D1120 |
Prophylaxis - child |
96 |
93 |
$4K |
| D4341 |
|
36 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
332 |
285 |
$2K |
| D4346 |
|
12 |
12 |
$765.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$427.00 |
| D1330 |
|
21 |
21 |
$0.00 |
| D0350 |
|
23 |
23 |
$0.00 |
| D0431 |
|
24 |
24 |
$0.00 |
| D9910 |
|
68 |
36 |
$0.00 |