| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
373 |
277 |
$178K |
| D0120 |
Periodic oral evaluation - established patient |
1,170 |
1,169 |
$63K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
840 |
829 |
$54K |
| D0210 |
Intraoral - complete series of radiographic images |
664 |
664 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,658 |
1,620 |
$30K |
| D2954 |
|
241 |
192 |
$25K |
| D0350 |
|
2,309 |
598 |
$22K |
| D9430 |
|
639 |
588 |
$20K |
| D0274 |
Bitewings - four radiographic images |
991 |
989 |
$20K |
| D1120 |
Prophylaxis - child |
482 |
481 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
790 |
774 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
88 |
55 |
$6K |
| D1110 |
Prophylaxis - adult |
64 |
64 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
75 |
51 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
15 |
$1K |
| D0270 |
|
48 |
43 |
$225.00 |