| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
171 |
133 |
$138K |
| D1110 |
Prophylaxis - adult |
920 |
911 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
477 |
287 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
751 |
747 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
170 |
118 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
444 |
437 |
$16K |
| D0274 |
Bitewings - four radiographic images |
451 |
445 |
$12K |
| D0330 |
Panoramic radiographic image |
151 |
149 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
108 |
74 |
$10K |
| D2954 |
|
35 |
26 |
$9K |
| D1120 |
Prophylaxis - child |
241 |
239 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
220 |
213 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
255 |
255 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
579 |
550 |
$4K |
| D2950 |
|
17 |
14 |
$2K |
| D0272 |
Bitewings - two radiographic images |
34 |
33 |
$668.10 |
| D1320 |
|
13 |
13 |
$383.24 |
| D0230 |
Intraoral - periapical each additional radiographic image |
40 |
34 |
$355.20 |