| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
120 |
84 |
$75K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
388 |
217 |
$47K |
| D1110 |
Prophylaxis - adult |
363 |
362 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
89 |
58 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
407 |
406 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
211 |
209 |
$8K |
| D2950 |
|
45 |
39 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
382 |
354 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
74 |
74 |
$3K |
| D0274 |
Bitewings - four radiographic images |
85 |
85 |
$3K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
42 |
42 |
$975.00 |