| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
2,848 |
791 |
$208K |
| D2740 |
Crown - porcelain/ceramic |
243 |
172 |
$140K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
163 |
106 |
$70K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,253 |
1,252 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
1,836 |
1,827 |
$58K |
| D4910 |
|
563 |
561 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
908 |
908 |
$49K |
| D1120 |
Prophylaxis - child |
1,043 |
1,041 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,124 |
1,122 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,696 |
1,690 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,844 |
1,751 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
304 |
165 |
$24K |
| D7240 |
Removal of impacted tooth - completely bony |
108 |
52 |
$24K |
| D1110 |
Prophylaxis - adult |
312 |
311 |
$23K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
169 |
93 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
215 |
98 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
168 |
87 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
227 |
222 |
$3K |
| D0330 |
Panoramic radiographic image |
62 |
62 |
$2K |
| D9430 |
|
13 |
13 |
$318.50 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$106.00 |
| D1999 |
|
205 |
198 |
$65.00 |
| D1330 |
|
30 |
29 |
$0.00 |
| D0180 |
|
18 |
18 |
$0.00 |