| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
74 |
45 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
114 |
51 |
$16K |
| D2950 |
|
112 |
71 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
39 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
132 |
132 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
14 |
$4K |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
34 |
34 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
76 |
76 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
174 |
159 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$881.63 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$649.56 |
| D4346 |
|
12 |
12 |
$563.40 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$367.08 |