| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
36 |
26 |
$26K |
| D1110 |
Prophylaxis - adult |
241 |
241 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
777 |
678 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
309 |
308 |
$8K |
| D2950 |
|
40 |
27 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
851 |
388 |
$6K |
| D4341 |
|
29 |
13 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
13 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
35 |
32 |
$2K |
| D0274 |
Bitewings - four radiographic images |
69 |
65 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
13 |
$834.21 |