| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
545 |
309 |
$355K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,764 |
1,637 |
$277K |
| D1110 |
Prophylaxis - adult |
4,170 |
4,149 |
$167K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,644 |
944 |
$127K |
| D0120 |
Periodic oral evaluation - established patient |
4,538 |
4,507 |
$101K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
797 |
565 |
$98K |
| D0210 |
Intraoral - complete series of radiographic images |
1,968 |
1,951 |
$97K |
| D0274 |
Bitewings - four radiographic images |
2,156 |
2,143 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,621 |
1,613 |
$52K |
| D1120 |
Prophylaxis - child |
1,114 |
1,111 |
$42K |
| D0140 |
Limited oral evaluation - problem focused |
1,292 |
1,268 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
3,146 |
3,065 |
$38K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
233 |
127 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,254 |
1,250 |
$28K |
| D2950 |
|
154 |
123 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,565 |
2,404 |
$18K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
16 |
16 |
$10K |
| D4355 |
|
101 |
101 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
81 |
37 |
$4K |
| D1351 |
Sealant - per tooth |
48 |
12 |
$1K |
| D2394 |
|
17 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$725.79 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$283.00 |