| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
281 |
210 |
$203K |
| D1110 |
Prophylaxis - adult |
2,719 |
2,649 |
$147K |
| D0120 |
Periodic oral evaluation - established patient |
2,936 |
2,868 |
$71K |
| D0274 |
Bitewings - four radiographic images |
1,570 |
1,531 |
$56K |
| D1206 |
Topical application of fluoride varnish |
1,549 |
1,529 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
852 |
837 |
$34K |
| D1120 |
Prophylaxis - child |
570 |
564 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
371 |
362 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
152 |
102 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
554 |
530 |
$9K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
16 |
14 |
$9K |
| D0330 |
Panoramic radiographic image |
107 |
104 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
38 |
$6K |
| D2950 |
|
15 |
13 |
$3K |
| D2954 |
|
13 |
13 |
$2K |
| D3120 |
|
65 |
37 |
$2K |