| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
145 |
96 |
$104K |
| D1110 |
Prophylaxis - adult |
1,197 |
1,144 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,328 |
1,282 |
$59K |
| D0210 |
Intraoral - complete series of radiographic images |
809 |
779 |
$58K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
350 |
156 |
$48K |
| D4341 |
|
313 |
97 |
$36K |
| D0274 |
Bitewings - four radiographic images |
810 |
779 |
$30K |
| D1120 |
Prophylaxis - child |
587 |
577 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
325 |
162 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
726 |
711 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
795 |
768 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
492 |
470 |
$19K |
| D2950 |
|
87 |
64 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
848 |
793 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
760 |
383 |
$8K |
| D4342 |
|
102 |
31 |
$8K |
| D1351 |
Sealant - per tooth |
184 |
40 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
25 |
$3K |
| D0272 |
Bitewings - two radiographic images |
66 |
66 |
$2K |
| D1206 |
Topical application of fluoride varnish |
21 |
21 |
$532.00 |