| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
147 |
62 |
$120K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
260 |
87 |
$34K |
| D1110 |
Prophylaxis - adult |
520 |
519 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
186 |
54 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
380 |
377 |
$16K |
| D2950 |
|
101 |
43 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
153 |
151 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
46 |
12 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
117 |
117 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
96 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
106 |
106 |
$2K |
| D0460 |
|
64 |
64 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
128 |
128 |
$2K |
| D0274 |
Bitewings - four radiographic images |
42 |
42 |
$1K |