| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
205 |
130 |
$130K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
520 |
258 |
$61K |
| D1110 |
Prophylaxis - adult |
895 |
895 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,021 |
1,021 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
483 |
482 |
$19K |
| D2950 |
|
104 |
73 |
$18K |
| D0330 |
Panoramic radiographic image |
382 |
381 |
$18K |
| D0274 |
Bitewings - four radiographic images |
644 |
643 |
$11K |
| D1206 |
Topical application of fluoride varnish |
395 |
395 |
$8K |
| D1120 |
Prophylaxis - child |
232 |
232 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
792 |
779 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
716 |
682 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
13 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
30 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$576.00 |