| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
91 |
72 |
$72K |
| D1110 |
Prophylaxis - adult |
1,287 |
1,261 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
1,617 |
1,596 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,193 |
1,176 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
357 |
195 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
398 |
202 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
725 |
721 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
927 |
924 |
$20K |
| D1120 |
Prophylaxis - child |
593 |
593 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
109 |
72 |
$12K |
| D0272 |
Bitewings - two radiographic images |
427 |
427 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
162 |
162 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
55 |
$4K |
| D0330 |
Panoramic radiographic image |
39 |
39 |
$2K |
| D2335 |
|
19 |
13 |
$2K |
| D2394 |
|
20 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
171 |
170 |
$1K |