| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
821 |
605 |
$390K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
2,020 |
1,209 |
$235K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,173 |
3,157 |
$201K |
| D0120 |
Periodic oral evaluation - established patient |
1,788 |
1,777 |
$108K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
201 |
191 |
$92K |
| D4341 |
|
1,193 |
316 |
$82K |
| D2952 |
|
762 |
606 |
$79K |
| D0210 |
Intraoral - complete series of radiographic images |
1,658 |
1,650 |
$78K |
| D9430 |
|
1,958 |
1,875 |
$62K |
| D1110 |
Prophylaxis - adult |
691 |
686 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
435 |
300 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,957 |
1,920 |
$23K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
33 |
25 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,654 |
1,183 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
741 |
733 |
$10K |
| D4910 |
|
123 |
123 |
$9K |
| D1206 |
Topical application of fluoride varnish |
430 |
430 |
$7K |
| D0274 |
Bitewings - four radiographic images |
253 |
253 |
$5K |
| D0330 |
Panoramic radiographic image |
117 |
117 |
$4K |
| D1120 |
Prophylaxis - child |
56 |
53 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
25 |
$2K |
| D4342 |
|
35 |
12 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
13 |
$1K |
| D5410 |
|
13 |
13 |
$455.00 |
| D5411 |
|
12 |
12 |
$420.00 |