| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
564 |
358 |
$302K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,399 |
842 |
$158K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
601 |
433 |
$82K |
| D2950 |
|
541 |
423 |
$74K |
| D1110 |
Prophylaxis - adult |
1,340 |
1,337 |
$65K |
| D0210 |
Intraoral - complete series of radiographic images |
1,099 |
1,075 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,283 |
1,280 |
$51K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
91 |
88 |
$45K |
| D0140 |
Limited oral evaluation - problem focused |
1,230 |
1,184 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
490 |
334 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
2,721 |
2,475 |
$39K |
| D1351 |
Sealant - per tooth |
1,017 |
132 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,139 |
1,133 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
365 |
224 |
$26K |
| D0274 |
Bitewings - four radiographic images |
920 |
917 |
$26K |
| D4341 |
|
213 |
80 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,821 |
1,323 |
$25K |
| D1120 |
Prophylaxis - child |
550 |
549 |
$23K |
| D1206 |
Topical application of fluoride varnish |
745 |
745 |
$21K |
| D3320 |
|
47 |
43 |
$19K |
| D4355 |
|
71 |
71 |
$6K |
| D0330 |
Panoramic radiographic image |
125 |
124 |
$6K |