| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
594 |
352 |
$322K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
158 |
137 |
$105K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
693 |
192 |
$85K |
| D0330 |
Panoramic radiographic image |
968 |
947 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
837 |
821 |
$19K |
| D1110 |
Prophylaxis - adult |
408 |
400 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
241 |
141 |
$17K |
| D1206 |
Topical application of fluoride varnish |
728 |
716 |
$16K |
| D0274 |
Bitewings - four radiographic images |
587 |
579 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
521 |
509 |
$15K |
| D4355 |
|
137 |
136 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
139 |
89 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
162 |
32 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
869 |
839 |
$10K |
| D5130 |
|
14 |
14 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,054 |
570 |
$8K |
| D3320 |
|
14 |
12 |
$7K |
| D2950 |
|
397 |
286 |
$6K |
| D4342 |
|
134 |
38 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
64 |
61 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$1K |
| D4910 |
|
22 |
20 |
$1K |
| D1120 |
Prophylaxis - child |
29 |
29 |
$959.25 |