| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
182 |
93 |
$121K |
| D1110 |
Prophylaxis - adult |
1,516 |
1,452 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
1,310 |
1,262 |
$30K |
| D0274 |
Bitewings - four radiographic images |
771 |
744 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
262 |
249 |
$11K |
| D0330 |
Panoramic radiographic image |
174 |
159 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
105 |
57 |
$8K |
| D1120 |
Prophylaxis - child |
127 |
124 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
198 |
164 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
400 |
380 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
163 |
160 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
49 |
49 |
$4K |
| D1206 |
Topical application of fluoride varnish |
107 |
105 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
197 |
181 |
$3K |