| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
831 |
650 |
$392K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
369 |
358 |
$169K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,290 |
653 |
$150K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,249 |
2,248 |
$146K |
| D0210 |
Intraoral - complete series of radiographic images |
1,886 |
1,885 |
$88K |
| D2954 |
|
739 |
601 |
$77K |
| D3320 |
|
145 |
128 |
$53K |
| D4341 |
|
699 |
189 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
650 |
237 |
$34K |
| D2330 |
|
328 |
99 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
317 |
152 |
$21K |
| D3310 |
|
65 |
43 |
$20K |
| D0350 |
|
2,128 |
774 |
$20K |
| D1110 |
Prophylaxis - adult |
229 |
229 |
$19K |
| D0330 |
Panoramic radiographic image |
605 |
605 |
$18K |
| D7240 |
Removal of impacted tooth - completely bony |
76 |
40 |
$18K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
161 |
102 |
$11K |
| D1120 |
Prophylaxis - child |
192 |
192 |
$10K |
| D2331 |
|
108 |
57 |
$8K |
| D2140 |
|
156 |
87 |
$8K |
| D4910 |
|
112 |
112 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
104 |
104 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
534 |
534 |
$7K |
| D9430 |
|
91 |
90 |
$3K |
| D1351 |
Sealant - per tooth |
49 |
12 |
$1K |
| D3221 |
|
14 |
13 |
$819.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
121 |
43 |
$490.05 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$300.00 |
| D0270 |
|
13 |
13 |
$65.00 |