| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
243 |
160 |
$128K |
| D1110 |
Prophylaxis - adult |
2,043 |
2,024 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
2,778 |
2,752 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
446 |
263 |
$61K |
| D0140 |
Limited oral evaluation - problem focused |
1,579 |
1,531 |
$53K |
| D7140 |
Extraction, erupted tooth or exposed root |
462 |
219 |
$46K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
89 |
58 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
500 |
499 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
912 |
897 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
2,631 |
2,558 |
$32K |
| D0274 |
Bitewings - four radiographic images |
945 |
937 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
56 |
42 |
$9K |
| D2950 |
|
74 |
58 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
36 |
$6K |
| D4342 |
|
65 |
30 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
119 |
119 |
$3K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$377.16 |