| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
18 |
12 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
347 |
193 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
128 |
85 |
$8K |
| D2950 |
|
118 |
87 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
186 |
105 |
$5K |
| D1110 |
Prophylaxis - adult |
276 |
271 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
213 |
207 |
$1K |
| D0274 |
Bitewings - four radiographic images |
122 |
118 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
132 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
118 |
114 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
68 |
57 |
$833.46 |
| D0220 |
Intraoral - periapical first radiographic image |
157 |
153 |
$711.44 |
| D0230 |
Intraoral - periapical each additional radiographic image |
51 |
40 |
$575.20 |
| D1206 |
Topical application of fluoride varnish |
22 |
18 |
$324.36 |
| D9994 |
|
223 |
223 |
$0.00 |
| D9630 |
|
135 |
132 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
37 |
23 |
$0.00 |
| D2750 |
|
17 |
12 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
19 |
19 |
$0.00 |
| D2330 |
|
20 |
14 |
$0.00 |
| D0330 |
Panoramic radiographic image |
91 |
91 |
$0.00 |