| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
432 |
289 |
$275K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,262 |
416 |
$163K |
| D1110 |
Prophylaxis - adult |
2,109 |
2,106 |
$105K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
828 |
515 |
$97K |
| D0210 |
Intraoral - complete series of radiographic images |
1,598 |
1,566 |
$93K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,027 |
2,020 |
$82K |
| D1351 |
Sealant - per tooth |
2,114 |
249 |
$65K |
| D2950 |
|
364 |
256 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,953 |
1,949 |
$51K |
| D1120 |
Prophylaxis - child |
1,080 |
1,080 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
880 |
863 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,054 |
1,052 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
2,077 |
2,015 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,254 |
1,254 |
$32K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
145 |
98 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,051 |
1,372 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
159 |
124 |
$14K |
| D0330 |
Panoramic radiographic image |
93 |
91 |
$3K |
| D4346 |
|
28 |
28 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
36 |
36 |
$703.00 |