| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
163 |
99 |
$112K |
| D2950 |
|
186 |
118 |
$28K |
| D1110 |
Prophylaxis - adult |
488 |
475 |
$26K |
| D0274 |
Bitewings - four radiographic images |
410 |
400 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
361 |
353 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
522 |
500 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
162 |
149 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
419 |
394 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
117 |
113 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
31 |
12 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
62 |
29 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
12 |
$370.00 |