| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
123 |
96 |
$100K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
228 |
132 |
$24K |
| D1110 |
Prophylaxis - adult |
329 |
326 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
154 |
153 |
$18K |
| D2954 |
|
64 |
56 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
159 |
82 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
296 |
293 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
190 |
189 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
154 |
154 |
$5K |
| D0274 |
Bitewings - four radiographic images |
91 |
91 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
66 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$2K |
| D0240 |
|
97 |
49 |
$2K |
| D1120 |
Prophylaxis - child |
48 |
48 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
175 |
168 |
$2K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$1K |
| D1206 |
Topical application of fluoride varnish |
21 |
18 |
$619.08 |