| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
83 |
50 |
$129K |
| D4341 |
|
232 |
106 |
$59K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
259 |
94 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
166 |
79 |
$39K |
| D2950 |
|
113 |
74 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
176 |
176 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
150 |
150 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
16 |
$6K |
| D1110 |
Prophylaxis - adult |
47 |
47 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
127 |
113 |
$2K |