| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,957 |
3,794 |
$196K |
| D2740 |
Crown - porcelain/ceramic |
185 |
125 |
$128K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
183 |
124 |
$100K |
| D0274 |
Bitewings - four radiographic images |
2,937 |
2,805 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
4,182 |
4,009 |
$94K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
867 |
480 |
$65K |
| D0210 |
Intraoral - complete series of radiographic images |
783 |
758 |
$53K |
| D1120 |
Prophylaxis - child |
1,107 |
1,051 |
$50K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
856 |
384 |
$49K |
| D2950 |
|
289 |
203 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
986 |
932 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,311 |
1,240 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
833 |
776 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,787 |
1,678 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,491 |
1,298 |
$18K |
| D4341 |
|
94 |
32 |
$11K |
| D4342 |
|
88 |
32 |
$7K |
| D1351 |
Sealant - per tooth |
205 |
39 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
46 |
25 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
27 |
$4K |
| D0272 |
Bitewings - two radiographic images |
39 |
38 |
$1K |