| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
358 |
223 |
$248K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
557 |
342 |
$71K |
| D1110 |
Prophylaxis - adult |
1,143 |
1,133 |
$61K |
| D2950 |
|
307 |
216 |
$56K |
| D1351 |
Sealant - per tooth |
1,780 |
201 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
854 |
847 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
2,033 |
1,858 |
$34K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
231 |
105 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
284 |
187 |
$28K |
| D0274 |
Bitewings - four radiographic images |
882 |
878 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
563 |
546 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
777 |
775 |
$21K |
| D1120 |
Prophylaxis - child |
459 |
457 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
297 |
278 |
$19K |
| D1206 |
Topical application of fluoride varnish |
718 |
710 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,774 |
1,164 |
$18K |
| D0330 |
Panoramic radiographic image |
216 |
215 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
39 |
$8K |
| D4341 |
|
67 |
30 |
$7K |
| D9310 |
|
46 |
46 |
$3K |
| D4355 |
|
12 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$324.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$174.13 |
| D0350 |
|
451 |
445 |
$0.00 |
| D0340 |
|
12 |
12 |
$0.00 |