| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
683 |
433 |
$440K |
| D0350 |
|
2,034 |
1,708 |
$182K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
692 |
323 |
$114K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
789 |
478 |
$107K |
| D4342 |
|
797 |
303 |
$103K |
| D0330 |
Panoramic radiographic image |
1,759 |
1,758 |
$94K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
856 |
438 |
$91K |
| D2950 |
|
676 |
453 |
$90K |
| D1110 |
Prophylaxis - adult |
1,265 |
1,264 |
$70K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,388 |
1,388 |
$62K |
| D0140 |
Limited oral evaluation - problem focused |
1,575 |
1,496 |
$61K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
259 |
187 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,320 |
1,319 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
677 |
677 |
$19K |
| D0460 |
|
572 |
529 |
$16K |
| D4341 |
|
38 |
13 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
645 |
635 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
341 |
341 |
$7K |
| D1206 |
Topical application of fluoride varnish |
141 |
141 |
$5K |
| D4910 |
|
38 |
38 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
414 |
414 |
$2K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$876.48 |