| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
242 |
201 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
1,749 |
1,746 |
$64K |
| D1110 |
Prophylaxis - adult |
772 |
769 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
860 |
684 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
686 |
683 |
$41K |
| D1120 |
Prophylaxis - child |
1,007 |
1,006 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
838 |
583 |
$39K |
| D1206 |
Topical application of fluoride varnish |
1,402 |
1,402 |
$34K |
| D9999 |
Unspecified adjunctive procedure, by report |
289 |
268 |
$34K |
| D9430 |
|
1,451 |
1,410 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
678 |
677 |
$23K |
| D4341 |
|
432 |
217 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
2,325 |
2,245 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,826 |
1,720 |
$14K |
| D0274 |
Bitewings - four radiographic images |
1,062 |
1,059 |
$12K |
| D4910 |
|
67 |
67 |
$3K |
| D0270 |
|
717 |
696 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
24 |
$2K |
| D2331 |
|
17 |
14 |
$1K |
| D0330 |
Panoramic radiographic image |
70 |
70 |
$913.50 |
| D2330 |
|
18 |
13 |
$872.00 |
| D0350 |
|
101 |
95 |
$712.40 |
| D0272 |
Bitewings - two radiographic images |
91 |
90 |
$599.00 |