| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
196 |
116 |
$93K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,323 |
601 |
$89K |
| D1110 |
Prophylaxis - adult |
948 |
948 |
$82K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,211 |
1,211 |
$80K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
847 |
425 |
$46K |
| D4341 |
|
654 |
177 |
$46K |
| D0210 |
Intraoral - complete series of radiographic images |
922 |
922 |
$44K |
| D2330 |
|
560 |
232 |
$43K |
| D0350 |
|
4,726 |
1,214 |
$43K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
262 |
176 |
$21K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
151 |
97 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,223 |
1,223 |
$18K |
| D1120 |
Prophylaxis - child |
205 |
205 |
$10K |
| D9430 |
|
248 |
225 |
$8K |
| D4910 |
|
99 |
99 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
68 |
68 |
$5K |
| D0330 |
Panoramic radiographic image |
147 |
147 |
$4K |
| D1351 |
Sealant - per tooth |
94 |
25 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
161 |
158 |
$2K |
| D4342 |
|
37 |
15 |
$2K |
| D0274 |
Bitewings - four radiographic images |
107 |
107 |
$1K |
| D0272 |
Bitewings - two radiographic images |
111 |
111 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
248 |
119 |
$1K |