| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
193 |
129 |
$140K |
| D1110 |
Prophylaxis - adult |
2,500 |
2,460 |
$129K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
723 |
409 |
$96K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
115 |
80 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
2,571 |
2,540 |
$58K |
| D0220 |
Intraoral - periapical first radiographic image |
2,945 |
2,798 |
$43K |
| D0140 |
Limited oral evaluation - problem focused |
1,124 |
1,099 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,128 |
1,113 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,701 |
1,603 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
311 |
158 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
238 |
165 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
408 |
402 |
$16K |
| D2950 |
|
97 |
70 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
519 |
517 |
$15K |
| D1120 |
Prophylaxis - child |
120 |
119 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
48 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$897.00 |