| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
255 |
129 |
$149K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
599 |
242 |
$80K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
205 |
103 |
$33K |
| D1110 |
Prophylaxis - adult |
548 |
545 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
180 |
65 |
$19K |
| D2950 |
|
137 |
63 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
443 |
442 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
403 |
387 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
192 |
189 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
424 |
414 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
379 |
376 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
543 |
528 |
$7K |
| D0274 |
Bitewings - four radiographic images |
161 |
161 |
$5K |
| D0460 |
|
71 |
70 |
$2K |