| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
363 |
239 |
$212K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,099 |
610 |
$114K |
| D2950 |
|
504 |
329 |
$78K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
831 |
436 |
$64K |
| D0210 |
Intraoral - complete series of radiographic images |
704 |
699 |
$38K |
| D1110 |
Prophylaxis - adult |
718 |
717 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
883 |
881 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,096 |
1,094 |
$30K |
| D1120 |
Prophylaxis - child |
573 |
572 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
103 |
56 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
466 |
465 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
573 |
569 |
$9K |
| D1206 |
Topical application of fluoride varnish |
339 |
339 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
54 |
25 |
$8K |
| D0274 |
Bitewings - four radiographic images |
252 |
252 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
203 |
199 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
581 |
313 |
$6K |
| D4355 |
|
27 |
27 |
$2K |
| D4346 |
|
28 |
28 |
$1K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$325.00 |