| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
361 |
232 |
$238K |
| D1110 |
Prophylaxis - adult |
2,225 |
2,159 |
$122K |
| D8670 |
Periodic orthodontic treatment visit |
416 |
409 |
$112K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
549 |
204 |
$77K |
| D0274 |
Bitewings - four radiographic images |
1,937 |
1,878 |
$71K |
| D2950 |
|
420 |
314 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
2,290 |
2,233 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
628 |
395 |
$53K |
| D1120 |
Prophylaxis - child |
988 |
965 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
887 |
861 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
1,012 |
959 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,222 |
1,198 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
540 |
317 |
$36K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
48 |
39 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
314 |
306 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
868 |
821 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
106 |
53 |
$9K |
| D0272 |
Bitewings - two radiographic images |
190 |
188 |
$6K |
| D9310 |
|
60 |
53 |
$3K |
| D1351 |
Sealant - per tooth |
73 |
16 |
$3K |
| D8660 |
|
16 |
16 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
55 |
42 |
$635.00 |
| D0350 |
|
13 |
13 |
$0.00 |
| D0470 |
|
13 |
13 |
$0.00 |