| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
151 |
108 |
$88K |
| D1351 |
Sealant - per tooth |
2,439 |
321 |
$69K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
603 |
372 |
$67K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
842 |
842 |
$34K |
| D1110 |
Prophylaxis - adult |
699 |
699 |
$34K |
| D1120 |
Prophylaxis - child |
748 |
748 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,149 |
1,144 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
916 |
915 |
$24K |
| D2950 |
|
146 |
121 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
478 |
462 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
375 |
367 |
$19K |
| D1206 |
Topical application of fluoride varnish |
535 |
534 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
850 |
787 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
95 |
72 |
$13K |
| D0330 |
Panoramic radiographic image |
211 |
211 |
$11K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
13 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
62 |
37 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
103 |
77 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
301 |
301 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
470 |
337 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
15 |
$2K |