| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
299 |
213 |
$185K |
| D1110 |
Prophylaxis - adult |
2,704 |
2,637 |
$102K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
193 |
136 |
$90K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,347 |
757 |
$69K |
| D0210 |
Intraoral - complete series of radiographic images |
1,668 |
1,619 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
1,905 |
1,852 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,934 |
1,888 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
705 |
417 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
447 |
293 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
327 |
316 |
$13K |
| D2950 |
|
187 |
144 |
$11K |
| D0274 |
Bitewings - four radiographic images |
1,179 |
1,141 |
$11K |
| D2952 |
|
75 |
55 |
$11K |
| D1120 |
Prophylaxis - child |
299 |
291 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
2,555 |
2,182 |
$9K |
| D3320 |
|
15 |
12 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
177 |
72 |
$7K |
| D2954 |
|
68 |
51 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,469 |
1,305 |
$6K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$5K |
| D1206 |
Topical application of fluoride varnish |
127 |
126 |
$3K |
| D1351 |
Sealant - per tooth |
108 |
12 |
$920.00 |
| D1330 |
|
173 |
168 |
$0.00 |