| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
144 |
65 |
$121K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
172 |
67 |
$23K |
| D2950 |
|
124 |
63 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
283 |
268 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
175 |
169 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
94 |
88 |
$7K |
| D1110 |
Prophylaxis - adult |
117 |
112 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
14 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
133 |
128 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
189 |
178 |
$2K |
| D0460 |
|
41 |
40 |
$1K |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$830.66 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$409.51 |