| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
517 |
334 |
$288K |
| D1110 |
Prophylaxis - adult |
1,123 |
1,117 |
$55K |
| D2950 |
|
400 |
277 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
989 |
987 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
237 |
148 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
363 |
360 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
558 |
553 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,016 |
1,001 |
$13K |
| D0274 |
Bitewings - four radiographic images |
323 |
319 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
375 |
372 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
37 |
25 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
159 |
158 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
24 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
34 |
$5K |
| D4910 |
|
24 |
24 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$618.24 |