| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
640 |
314 |
$435K |
| D2950 |
|
583 |
307 |
$77K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
465 |
224 |
$63K |
| D1110 |
Prophylaxis - adult |
1,305 |
1,284 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,530 |
1,496 |
$60K |
| D4342 |
|
460 |
143 |
$48K |
| D0210 |
Intraoral - complete series of radiographic images |
447 |
446 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,411 |
1,409 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
165 |
92 |
$27K |
| D0274 |
Bitewings - four radiographic images |
608 |
607 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
158 |
157 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
386 |
384 |
$5K |
| D4910 |
|
39 |
39 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
40 |
39 |
$472.98 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$362.09 |