| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
65 |
52 |
$36K |
| D1110 |
Prophylaxis - adult |
762 |
758 |
$32K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
47 |
39 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
711 |
709 |
$20K |
| D0274 |
Bitewings - four radiographic images |
515 |
512 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
893 |
865 |
$4K |
| D2954 |
|
45 |
39 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
712 |
679 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
176 |
169 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
40 |
40 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
14 |
14 |
$630.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$585.00 |
| D0272 |
Bitewings - two radiographic images |
53 |
53 |
$530.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
18 |
$450.00 |
| D0270 |
|
24 |
24 |
$120.00 |
| D1206 |
Topical application of fluoride varnish |
46 |
42 |
$0.00 |