| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
153 |
100 |
$125K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
193 |
131 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
338 |
334 |
$17K |
| D1110 |
Prophylaxis - adult |
243 |
238 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
111 |
67 |
$11K |
| D0330 |
Panoramic radiographic image |
118 |
114 |
$10K |
| D2954 |
|
31 |
24 |
$8K |
| D0274 |
Bitewings - four radiographic images |
151 |
151 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
68 |
63 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
123 |
119 |
$1K |
| D1120 |
Prophylaxis - child |
31 |
31 |
$1K |
| D1320 |
|
36 |
36 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
32 |
30 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
96 |
49 |
$943.68 |