| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
736 |
472 |
$320K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,171 |
615 |
$72K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
158 |
130 |
$71K |
| D2954 |
|
660 |
438 |
$55K |
| D1110 |
Prophylaxis - adult |
1,033 |
1,009 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
784 |
446 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
677 |
656 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
467 |
288 |
$35K |
| D4341 |
|
531 |
174 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
829 |
808 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
760 |
728 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
613 |
598 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
215 |
138 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
141 |
107 |
$11K |
| D3310 |
|
28 |
17 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,398 |
1,329 |
$6K |
| D0274 |
Bitewings - four radiographic images |
653 |
638 |
$6K |
| D4910 |
|
100 |
94 |
$5K |
| D3320 |
|
14 |
13 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,168 |
887 |
$3K |
| D0330 |
Panoramic radiographic image |
122 |
121 |
$3K |
| D9310 |
|
45 |
45 |
$942.00 |
| D4355 |
|
17 |
13 |
$716.00 |
| D1120 |
Prophylaxis - child |
13 |
12 |
$495.00 |
| D0270 |
|
81 |
78 |
$249.25 |
| D0350 |
|
13 |
13 |
$20.00 |