| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
155 |
77 |
$91K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
431 |
203 |
$59K |
| D1110 |
Prophylaxis - adult |
1,059 |
1,043 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
522 |
496 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
73 |
51 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
494 |
484 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
93 |
93 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
128 |
127 |
$4K |
| D1206 |
Topical application of fluoride varnish |
245 |
242 |
$4K |
| D0274 |
Bitewings - four radiographic images |
141 |
141 |
$4K |
| D2950 |
|
31 |
24 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
247 |
244 |
$3K |
| D1120 |
Prophylaxis - child |
86 |
84 |
$3K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$1K |
| D0180 |
|
24 |
24 |
$984.24 |
| D0270 |
|
12 |
12 |
$162.24 |