| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
282 |
163 |
$178K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
398 |
220 |
$51K |
| D1110 |
Prophylaxis - adult |
685 |
684 |
$35K |
| D2950 |
|
162 |
91 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,334 |
1,217 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
468 |
467 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
650 |
648 |
$17K |
| D0274 |
Bitewings - four radiographic images |
533 |
532 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
307 |
301 |
$14K |
| D1120 |
Prophylaxis - child |
336 |
336 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,279 |
784 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
122 |
59 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
127 |
117 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
43 |
26 |
$7K |
| D1206 |
Topical application of fluoride varnish |
245 |
244 |
$5K |
| D0330 |
Panoramic radiographic image |
72 |
71 |
$4K |
| D4346 |
|
13 |
13 |
$792.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
35 |
35 |
$696.00 |
| D0350 |
|
344 |
340 |
$0.00 |