| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
1,659 |
1,155 |
$786K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
617 |
543 |
$279K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,444 |
2,436 |
$158K |
| D0210 |
Intraoral - complete series of radiographic images |
3,031 |
3,026 |
$143K |
| D1110 |
Prophylaxis - adult |
1,566 |
1,561 |
$135K |
| D0120 |
Periodic oral evaluation - established patient |
1,281 |
1,271 |
$99K |
| D2954 |
|
913 |
714 |
$95K |
| D1351 |
Sealant - per tooth |
2,658 |
541 |
$93K |
| D3320 |
|
236 |
201 |
$86K |
| D1120 |
Prophylaxis - child |
1,554 |
1,542 |
$75K |
| D9430 |
|
1,793 |
1,779 |
$57K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
442 |
266 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,796 |
2,781 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
642 |
433 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
410 |
307 |
$27K |
| D0274 |
Bitewings - four radiographic images |
1,207 |
1,193 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,754 |
1,626 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
826 |
815 |
$10K |
| D0350 |
|
999 |
640 |
$10K |
| D3310 |
|
25 |
16 |
$7K |
| D4341 |
|
72 |
25 |
$5K |
| D1206 |
Topical application of fluoride varnish |
232 |
232 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$780.00 |