| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
98 |
55 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
246 |
120 |
$17K |
| D1110 |
Prophylaxis - adult |
474 |
390 |
$15K |
| D1206 |
Topical application of fluoride varnish |
520 |
431 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
295 |
246 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
117 |
113 |
$6K |
| D0330 |
Panoramic radiographic image |
200 |
174 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
286 |
230 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
26 |
$3K |
| D0274 |
Bitewings - four radiographic images |
200 |
163 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
195 |
169 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
15 |
$2K |
| D4355 |
|
15 |
14 |
$972.50 |
| D1120 |
Prophylaxis - child |
45 |
29 |
$566.14 |
| D0220 |
Intraoral - periapical first radiographic image |
63 |
43 |
$486.78 |