| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
376 |
237 |
$245K |
| D1110 |
Prophylaxis - adult |
2,873 |
2,744 |
$146K |
| D8670 |
Periodic orthodontic treatment visit |
259 |
234 |
$51K |
| D0274 |
Bitewings - four radiographic images |
1,188 |
1,138 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,904 |
1,819 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
548 |
360 |
$39K |
| D4341 |
|
247 |
72 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
457 |
431 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
463 |
284 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
1,674 |
1,536 |
$24K |
| D2950 |
|
156 |
111 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
537 |
508 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
422 |
385 |
$16K |
| D9110 |
|
246 |
235 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,008 |
869 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
128 |
95 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
220 |
209 |
$5K |
| D9310 |
|
35 |
35 |
$2K |
| D8680 |
|
17 |
17 |
$1K |
| D1206 |
Topical application of fluoride varnish |
41 |
40 |
$1K |
| D3120 |
|
16 |
14 |
$488.00 |