| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
61 |
42 |
$25K |
| D1120 |
Prophylaxis - child |
352 |
299 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
528 |
460 |
$12K |
| D1206 |
Topical application of fluoride varnish |
495 |
429 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
50 |
$5K |
| D1110 |
Prophylaxis - adult |
133 |
119 |
$4K |
| D4910 |
|
55 |
54 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
71 |
45 |
$3K |
| D0274 |
Bitewings - four radiographic images |
98 |
84 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$992.40 |
| D0220 |
Intraoral - periapical first radiographic image |
84 |
69 |
$648.51 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
25 |
$601.18 |
| D0272 |
Bitewings - two radiographic images |
23 |
15 |
$216.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
14 |
$91.20 |
| D1999 |
|
13 |
13 |
$0.00 |