| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
55 |
25 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
182 |
83 |
$12K |
| D1206 |
Topical application of fluoride varnish |
383 |
304 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
220 |
206 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
306 |
230 |
$5K |
| D1120 |
Prophylaxis - child |
193 |
154 |
$5K |
| D1110 |
Prophylaxis - adult |
130 |
100 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
43 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
72 |
58 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
15 |
$1K |
| D0330 |
Panoramic radiographic image |
29 |
27 |
$971.36 |
| D0272 |
Bitewings - two radiographic images |
38 |
28 |
$391.29 |
| D0220 |
Intraoral - periapical first radiographic image |
33 |
29 |
$366.72 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$219.60 |