| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
472 |
295 |
$301K |
| D1110 |
Prophylaxis - adult |
1,636 |
1,525 |
$87K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
714 |
348 |
$59K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
734 |
301 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,165 |
1,102 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,431 |
1,361 |
$33K |
| D2950 |
|
207 |
138 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
397 |
375 |
$29K |
| D4342 |
|
283 |
108 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
487 |
455 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,305 |
1,220 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
468 |
421 |
$17K |
| D1120 |
Prophylaxis - child |
330 |
316 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
526 |
509 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,255 |
991 |
$15K |
| D1351 |
Sealant - per tooth |
126 |
30 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
19 |
14 |
$3K |
| D9310 |
|
16 |
16 |
$945.00 |