| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
262 |
160 |
$164K |
| D1110 |
Prophylaxis - adult |
1,200 |
1,066 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
701 |
327 |
$47K |
| D0140 |
Limited oral evaluation - problem focused |
985 |
856 |
$35K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
135 |
79 |
$19K |
| D0274 |
Bitewings - four radiographic images |
575 |
509 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
439 |
394 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
727 |
659 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,082 |
877 |
$14K |
| D2950 |
|
63 |
38 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
88 |
82 |
$6K |
| D0330 |
Panoramic radiographic image |
59 |
47 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
352 |
157 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
13 |
$935.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$677.00 |
| D0270 |
|
53 |
41 |
$510.00 |
| D1999 |
|
109 |
98 |
$0.00 |