| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
201 |
135 |
$96K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,019 |
1,016 |
$67K |
| D0210 |
Intraoral - complete series of radiographic images |
862 |
861 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
126 |
73 |
$8K |
| D0350 |
|
893 |
253 |
$8K |
| D9430 |
|
249 |
227 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
39 |
12 |
$5K |
| D2952 |
|
35 |
24 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
44 |
44 |
$3K |
| D4910 |
|
27 |
27 |
$2K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
45 |
44 |
$928.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
85 |
44 |
$344.25 |