| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
629 |
297 |
$447K |
| D2950 |
|
976 |
543 |
$157K |
| D1351 |
Sealant - per tooth |
3,795 |
404 |
$116K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,256 |
278 |
$111K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
150 |
133 |
$96K |
| D5226 |
|
101 |
101 |
$92K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
584 |
357 |
$77K |
| D0330 |
Panoramic radiographic image |
1,054 |
1,053 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,258 |
1,257 |
$58K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
348 |
171 |
$56K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
506 |
318 |
$52K |
| D4341 |
|
313 |
98 |
$46K |
| D3320 |
|
64 |
53 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
797 |
781 |
$34K |
| D1110 |
Prophylaxis - adult |
569 |
568 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,096 |
1,095 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,857 |
1,802 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,302 |
1,128 |
$16K |
| D5225 |
|
17 |
17 |
$15K |
| D1120 |
Prophylaxis - child |
267 |
267 |
$12K |
| D3310 |
|
24 |
13 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
448 |
446 |
$10K |
| D4346 |
|
141 |
141 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
54 |
37 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
257 |
256 |
$8K |
| D4355 |
|
25 |
25 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
215 |
59 |
$2K |
| D0180 |
|
32 |
32 |
$1K |
| D0272 |
Bitewings - two radiographic images |
61 |
61 |
$988.31 |