| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
424 |
141 |
$288K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,103 |
269 |
$78K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
638 |
195 |
$75K |
| D2950 |
|
373 |
130 |
$69K |
| D0210 |
Intraoral - complete series of radiographic images |
1,277 |
1,241 |
$68K |
| D1110 |
Prophylaxis - adult |
1,310 |
1,303 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,529 |
1,523 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
513 |
277 |
$53K |
| D0140 |
Limited oral evaluation - problem focused |
1,307 |
1,243 |
$48K |
| D0220 |
Intraoral - periapical first radiographic image |
2,100 |
1,977 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
980 |
974 |
$25K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
251 |
101 |
$24K |
| D1120 |
Prophylaxis - child |
426 |
426 |
$17K |
| D0274 |
Bitewings - four radiographic images |
555 |
551 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,905 |
1,312 |
$15K |
| D5214 |
|
12 |
12 |
$13K |
| D5213 |
|
12 |
12 |
$11K |
| D1206 |
Topical application of fluoride varnish |
233 |
233 |
$6K |
| D4341 |
|
26 |
12 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
138 |
138 |
$3K |
| D0270 |
|
116 |
103 |
$938.02 |
| D0272 |
Bitewings - two radiographic images |
21 |
18 |
$333.81 |
| D0603 |
|
12 |
12 |
$0.00 |