| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
372 |
240 |
$190K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,044 |
645 |
$76K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
571 |
146 |
$69K |
| D1110 |
Prophylaxis - adult |
1,378 |
1,327 |
$59K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
76 |
66 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,388 |
1,340 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,030 |
993 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,367 |
1,329 |
$29K |
| D1120 |
Prophylaxis - child |
894 |
859 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,000 |
954 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
246 |
157 |
$19K |
| D0330 |
Panoramic radiographic image |
481 |
462 |
$17K |
| D9110 |
|
249 |
218 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
285 |
266 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
499 |
451 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
280 |
267 |
$5K |
| D1351 |
Sealant - per tooth |
190 |
47 |
$5K |
| D0272 |
Bitewings - two radiographic images |
128 |
127 |
$2K |
| D4355 |
|
16 |
13 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
12 |
$993.02 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$811.07 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
13 |
$799.44 |
| D2950 |
|
15 |
12 |
$798.42 |
| D0230 |
Intraoral - periapical each additional radiographic image |
73 |
58 |
$578.54 |