| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
1,409 |
799 |
$545K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
607 |
488 |
$445K |
| D2750 |
|
617 |
359 |
$258K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,699 |
853 |
$230K |
| D1110 |
Prophylaxis - adult |
2,695 |
2,675 |
$175K |
| D2950 |
|
2,012 |
1,146 |
$169K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,736 |
2,716 |
$150K |
| D0330 |
Panoramic radiographic image |
2,940 |
2,906 |
$132K |
| D3320 |
|
164 |
125 |
$102K |
| D1206 |
Topical application of fluoride varnish |
3,257 |
3,231 |
$83K |
| D7140 |
Extraction, erupted tooth or exposed root |
633 |
254 |
$82K |
| D0140 |
Limited oral evaluation - problem focused |
1,488 |
1,452 |
$69K |
| D0274 |
Bitewings - four radiographic images |
2,862 |
2,833 |
$67K |
| D0220 |
Intraoral - periapical first radiographic image |
4,870 |
4,353 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,669 |
1,659 |
$52K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
275 |
185 |
$47K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,922 |
1,860 |
$34K |
| D1351 |
Sealant - per tooth |
714 |
108 |
$25K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
185 |
72 |
$20K |
| D1120 |
Prophylaxis - child |
268 |
263 |
$12K |
| D4355 |
|
104 |
104 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
84 |
49 |
$8K |
| D1330 |
|
472 |
468 |
$3K |
| D4341 |
|
28 |
12 |
$3K |
| D0270 |
|
84 |
76 |
$684.00 |
| D3120 |
|
19 |
16 |
$665.00 |