| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
153 |
88 |
$100K |
| D1110 |
Prophylaxis - adult |
1,752 |
1,749 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
2,293 |
2,289 |
$61K |
| D1120 |
Prophylaxis - child |
778 |
778 |
$31K |
| D0274 |
Bitewings - four radiographic images |
879 |
878 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
515 |
515 |
$23K |
| D2950 |
|
125 |
85 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
155 |
92 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
812 |
812 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
229 |
228 |
$18K |
| D1351 |
Sealant - per tooth |
540 |
57 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,008 |
995 |
$16K |
| D1206 |
Topical application of fluoride varnish |
576 |
576 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
105 |
64 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
718 |
696 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$430.50 |
| D1999 |
|
104 |
102 |
$0.00 |