| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
119 |
94 |
$48K |
| D1110 |
Prophylaxis - adult |
863 |
861 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,135 |
1,132 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
238 |
142 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,148 |
1,094 |
$5K |
| D1120 |
Prophylaxis - child |
164 |
164 |
$5K |
| D0274 |
Bitewings - four radiographic images |
346 |
345 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
45 |
$4K |
| D1206 |
Topical application of fluoride varnish |
193 |
193 |
$4K |
| D2950 |
|
57 |
48 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
127 |
124 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
705 |
676 |
$2K |
| D0251 |
|
130 |
130 |
$1K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$750.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$600.00 |
| D0272 |
Bitewings - two radiographic images |
70 |
70 |
$330.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$300.00 |