| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
223 |
128 |
$106K |
| D4910 |
|
1,038 |
1,036 |
$79K |
| D1110 |
Prophylaxis - adult |
775 |
771 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
972 |
970 |
$56K |
| D0210 |
Intraoral - complete series of radiographic images |
767 |
757 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
361 |
360 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
134 |
83 |
$11K |
| D4341 |
|
142 |
41 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,867 |
344 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
107 |
62 |
$7K |
| D0274 |
Bitewings - four radiographic images |
291 |
291 |
$6K |
| D2954 |
|
15 |
14 |
$2K |
| D0350 |
|
68 |
56 |
$493.20 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
38 |
$440.00 |
| D9430 |
|
12 |
12 |
$336.00 |