| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
295 |
229 |
$195K |
| D1110 |
Prophylaxis - adult |
3,892 |
3,774 |
$194K |
| D0120 |
Periodic oral evaluation - established patient |
3,139 |
3,045 |
$67K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
101 |
69 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,589 |
1,545 |
$53K |
| D0220 |
Intraoral - periapical first radiographic image |
2,517 |
2,410 |
$36K |
| D0330 |
Panoramic radiographic image |
390 |
374 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,880 |
1,795 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
590 |
563 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
344 |
166 |
$19K |
| D1120 |
Prophylaxis - child |
256 |
251 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
134 |
83 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
217 |
209 |
$8K |
| D2954 |
|
19 |
13 |
$3K |
| D1206 |
Topical application of fluoride varnish |
100 |
98 |
$3K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$350.00 |