| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
289 |
227 |
$159K |
| D1110 |
Prophylaxis - adult |
1,464 |
1,462 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
1,552 |
1,547 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
339 |
190 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
513 |
503 |
$23K |
| D0274 |
Bitewings - four radiographic images |
1,287 |
1,284 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
238 |
132 |
$12K |
| D2954 |
|
126 |
106 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
113 |
92 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,914 |
1,893 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,575 |
1,569 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
125 |
61 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
83 |
83 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
41 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
44 |
$1K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$640.00 |