| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
730 |
202 |
$512K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
633 |
268 |
$99K |
| D2950 |
|
705 |
198 |
$94K |
| D2394 |
|
297 |
124 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
407 |
188 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
612 |
612 |
$25K |
| D4342 |
|
146 |
49 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
172 |
171 |
$15K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
59 |
13 |
$10K |
| D0274 |
Bitewings - four radiographic images |
130 |
129 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
153 |
153 |
$4K |
| D1110 |
Prophylaxis - adult |
56 |
56 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$905.19 |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
52 |
$681.17 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$155.40 |