| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
274 |
221 |
$149K |
| D1110 |
Prophylaxis - adult |
2,669 |
2,664 |
$124K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,383 |
828 |
$100K |
| D1206 |
Topical application of fluoride varnish |
2,349 |
2,345 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
2,656 |
2,650 |
$69K |
| D0210 |
Intraoral - complete series of radiographic images |
689 |
689 |
$32K |
| D1120 |
Prophylaxis - child |
668 |
667 |
$31K |
| D0274 |
Bitewings - four radiographic images |
2,394 |
2,386 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
611 |
606 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
902 |
902 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,707 |
2,676 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
313 |
218 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
3,211 |
3,182 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
538 |
537 |
$14K |
| D2954 |
|
150 |
113 |
$13K |
| D0602 |
|
301 |
301 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$1K |
| D0270 |
|
213 |
212 |
$1K |
| D0272 |
Bitewings - two radiographic images |
41 |
41 |
$377.50 |
| D1330 |
|
389 |
388 |
$0.00 |