| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
238 |
170 |
$172K |
| D1110 |
Prophylaxis - adult |
2,234 |
2,226 |
$127K |
| D0120 |
Periodic oral evaluation - established patient |
2,602 |
2,595 |
$65K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
456 |
301 |
$42K |
| D0274 |
Bitewings - four radiographic images |
815 |
815 |
$31K |
| D1120 |
Prophylaxis - child |
558 |
557 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,617 |
1,599 |
$27K |
| D2950 |
|
149 |
112 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
601 |
600 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
375 |
370 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
401 |
398 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,082 |
1,047 |
$15K |
| D0330 |
Panoramic radiographic image |
208 |
207 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
190 |
186 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
157 |
102 |
$11K |
| D1206 |
Topical application of fluoride varnish |
111 |
111 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
16 |
13 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
19 |
$2K |
| D1351 |
Sealant - per tooth |
55 |
12 |
$2K |
| D0180 |
|
22 |
22 |
$798.00 |