| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
38 |
27 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
174 |
105 |
$15K |
| D1110 |
Prophylaxis - adult |
266 |
260 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
272 |
268 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
109 |
66 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,256 |
579 |
$9K |
| D2332 |
|
58 |
29 |
$8K |
| D0274 |
Bitewings - four radiographic images |
243 |
237 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
253 |
251 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
70 |
50 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
844 |
810 |
$6K |
| D0330 |
Panoramic radiographic image |
73 |
70 |
$6K |
| D1120 |
Prophylaxis - child |
115 |
115 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
137 |
136 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
93 |
91 |
$3K |
| D0350 |
|
80 |
80 |
$2K |
| D2950 |
|
13 |
12 |
$2K |
| D2394 |
|
17 |
12 |
$1K |
| D2330 |
|
14 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
35 |
35 |
$687.75 |
| D1206 |
Topical application of fluoride varnish |
30 |
30 |
$450.00 |