| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
181 |
111 |
$86K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
545 |
541 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
458 |
199 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
487 |
485 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
220 |
117 |
$17K |
| D9430 |
|
195 |
185 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
94 |
55 |
$5K |
| D2954 |
|
38 |
27 |
$4K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
29 |
12 |
$3K |
| D4910 |
|
26 |
26 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
24 |
24 |
$2K |
| D1120 |
Prophylaxis - child |
29 |
29 |
$1K |
| D1206 |
Topical application of fluoride varnish |
85 |
85 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
81 |
79 |
$972.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
84 |
84 |
$772.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
111 |
69 |
$445.50 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$172.80 |