| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
339 |
270 |
$161K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,904 |
1,891 |
$122K |
| D0120 |
Periodic oral evaluation - established patient |
1,367 |
1,353 |
$91K |
| D0210 |
Intraoral - complete series of radiographic images |
1,778 |
1,773 |
$83K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,464 |
705 |
$79K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,192 |
687 |
$79K |
| D1120 |
Prophylaxis - child |
1,080 |
1,068 |
$44K |
| D4341 |
|
565 |
150 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,682 |
1,866 |
$36K |
| D1110 |
Prophylaxis - adult |
285 |
285 |
$25K |
| D2954 |
|
216 |
177 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,718 |
1,705 |
$22K |
| D0350 |
|
1,419 |
556 |
$13K |
| D9430 |
|
379 |
368 |
$12K |
| D4910 |
|
136 |
136 |
$10K |
| D0272 |
Bitewings - two radiographic images |
702 |
701 |
$8K |
| D0274 |
Bitewings - four radiographic images |
392 |
383 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
66 |
55 |
$8K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
14 |
14 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
20 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$276.00 |