| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
649 |
358 |
$309K |
| D9430 |
|
5,275 |
4,253 |
$168K |
| D1110 |
Prophylaxis - adult |
1,854 |
1,849 |
$165K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,740 |
1,738 |
$115K |
| D0120 |
Periodic oral evaluation - established patient |
1,137 |
1,135 |
$92K |
| D0210 |
Intraoral - complete series of radiographic images |
1,616 |
1,613 |
$77K |
| D2954 |
|
532 |
314 |
$56K |
| D2394 |
|
600 |
370 |
$50K |
| D1206 |
Topical application of fluoride varnish |
2,254 |
2,247 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
472 |
245 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,342 |
1,803 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,112 |
1,110 |
$22K |
| D1120 |
Prophylaxis - child |
379 |
376 |
$18K |
| D4910 |
|
123 |
123 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
740 |
727 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
110 |
59 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
50 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
32 |
12 |
$4K |
| D2335 |
|
27 |
13 |
$3K |
| D2332 |
|
31 |
12 |
$3K |
| D0350 |
|
223 |
71 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
29 |
$358.00 |