| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
179 |
107 |
$140K |
| D1110 |
Prophylaxis - adult |
406 |
384 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
175 |
89 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
410 |
393 |
$12K |
| D0274 |
Bitewings - four radiographic images |
227 |
212 |
$8K |
| D2950 |
|
46 |
27 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
146 |
126 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
144 |
140 |
$4K |
| D0330 |
Panoramic radiographic image |
66 |
62 |
$4K |
| D1120 |
Prophylaxis - child |
111 |
109 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
335 |
311 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
15 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
144 |
88 |
$1K |
| D1320 |
|
53 |
51 |
$816.00 |