| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
257 |
168 |
$122K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,713 |
1,705 |
$107K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,774 |
782 |
$95K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,298 |
730 |
$85K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
461 |
233 |
$52K |
| D0210 |
Intraoral - complete series of radiographic images |
1,099 |
1,095 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
876 |
870 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,313 |
1,680 |
$36K |
| D1120 |
Prophylaxis - child |
1,102 |
1,098 |
$35K |
| D9430 |
|
1,025 |
780 |
$31K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
443 |
206 |
$28K |
| D1110 |
Prophylaxis - adult |
287 |
283 |
$22K |
| D0274 |
Bitewings - four radiographic images |
882 |
874 |
$17K |
| D4341 |
|
218 |
62 |
$15K |
| D2954 |
|
143 |
94 |
$15K |
| D0350 |
|
1,450 |
654 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
138 |
93 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
821 |
814 |
$7K |
| D3320 |
|
13 |
12 |
$5K |
| D1351 |
Sealant - per tooth |
223 |
71 |
$4K |
| D2140 |
|
82 |
27 |
$4K |
| D1206 |
Topical application of fluoride varnish |
209 |
209 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
80 |
79 |
$882.00 |
| D0272 |
Bitewings - two radiographic images |
34 |
34 |
$340.00 |
| D9993 |
|
38 |
38 |
$0.00 |
| D1310 |
|
51 |
51 |
$0.00 |
| D0601 |
|
13 |
13 |
$0.00 |