| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
517 |
264 |
$341K |
| D1110 |
Prophylaxis - adult |
6,167 |
5,939 |
$326K |
| D8670 |
Periodic orthodontic treatment visit |
523 |
451 |
$114K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
196 |
131 |
$104K |
| D0274 |
Bitewings - four radiographic images |
2,696 |
2,602 |
$97K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,273 |
790 |
$96K |
| D0220 |
Intraoral - periapical first radiographic image |
4,598 |
4,250 |
$69K |
| D0140 |
Limited oral evaluation - problem focused |
1,752 |
1,666 |
$66K |
| D0210 |
Intraoral - complete series of radiographic images |
857 |
815 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
2,580 |
2,465 |
$58K |
| D1206 |
Topical application of fluoride varnish |
2,233 |
2,174 |
$56K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
732 |
444 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,636 |
2,047 |
$32K |
| D1120 |
Prophylaxis - child |
454 |
440 |
$22K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
168 |
70 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
422 |
398 |
$17K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$3K |
| D1351 |
Sealant - per tooth |
36 |
13 |
$1K |
| D2331 |
|
14 |
12 |
$1K |
| D0180 |
|
28 |
27 |
$999.00 |