| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
323 |
234 |
$153K |
| D0120 |
Periodic oral evaluation - established patient |
1,118 |
1,112 |
$74K |
| D1110 |
Prophylaxis - adult |
671 |
668 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
730 |
727 |
$47K |
| D0210 |
Intraoral - complete series of radiographic images |
684 |
678 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,564 |
1,266 |
$27K |
| D1120 |
Prophylaxis - child |
512 |
508 |
$25K |
| D1206 |
Topical application of fluoride varnish |
1,325 |
1,314 |
$20K |
| D0274 |
Bitewings - four radiographic images |
728 |
726 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
233 |
135 |
$15K |
| D4910 |
|
122 |
122 |
$9K |
| D4341 |
|
77 |
26 |
$5K |
| D9430 |
|
119 |
113 |
$4K |
| D2954 |
|
14 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
13 |
$180.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |