| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
87 |
71 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
337 |
179 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
171 |
114 |
$16K |
| D1110 |
Prophylaxis - adult |
287 |
285 |
$14K |
| D2950 |
|
84 |
69 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
278 |
278 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
109 |
109 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
190 |
189 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
183 |
180 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
62 |
62 |
$3K |
| D0274 |
Bitewings - four radiographic images |
73 |
73 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
14 |
$2K |
| D1206 |
Topical application of fluoride varnish |
56 |
56 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
125 |
104 |
$1K |
| D1354 |
|
34 |
15 |
$870.89 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$543.15 |