| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
491 |
337 |
$320K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
750 |
421 |
$97K |
| D2950 |
|
417 |
300 |
$73K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
337 |
156 |
$54K |
| D1110 |
Prophylaxis - adult |
795 |
791 |
$40K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
249 |
167 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
554 |
553 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
859 |
859 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
326 |
201 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
1,153 |
1,039 |
$19K |
| D4341 |
|
94 |
38 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
298 |
283 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
453 |
453 |
$12K |
| D1206 |
Topical application of fluoride varnish |
645 |
638 |
$9K |
| D0274 |
Bitewings - four radiographic images |
312 |
311 |
$8K |
| D1120 |
Prophylaxis - child |
158 |
158 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
461 |
411 |
$4K |
| D0330 |
Panoramic radiographic image |
43 |
41 |
$1K |
| D4910 |
|
13 |
12 |
$707.00 |
| D0180 |
|
15 |
15 |
$600.00 |
| D0431 |
|
81 |
79 |
$0.00 |