| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
711 |
283 |
$293K |
| D2740 |
Crown - porcelain/ceramic |
407 |
194 |
$267K |
| D1110 |
Prophylaxis - adult |
2,847 |
2,733 |
$143K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,453 |
726 |
$106K |
| D0210 |
Intraoral - complete series of radiographic images |
965 |
914 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,561 |
1,482 |
$63K |
| D0274 |
Bitewings - four radiographic images |
1,642 |
1,564 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
2,297 |
2,219 |
$52K |
| D0140 |
Limited oral evaluation - problem focused |
1,239 |
1,149 |
$44K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
549 |
331 |
$42K |
| D2950 |
|
231 |
156 |
$35K |
| D1120 |
Prophylaxis - child |
564 |
548 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
943 |
900 |
$27K |
| D2335 |
|
176 |
59 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,399 |
1,294 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
359 |
181 |
$19K |
| D2394 |
|
171 |
103 |
$18K |
| D8670 |
Periodic orthodontic treatment visit |
56 |
56 |
$16K |
| D9310 |
|
327 |
233 |
$14K |
| D8660 |
|
116 |
80 |
$6K |
| D4341 |
|
39 |
13 |
$5K |
| D1351 |
Sealant - per tooth |
58 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
196 |
143 |
$2K |
| D0330 |
Panoramic radiographic image |
16 |
12 |
$800.00 |
| D0270 |
|
30 |
27 |
$376.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
12 |
$256.00 |