| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
492 |
345 |
$364K |
| D1351 |
Sealant - per tooth |
7,057 |
897 |
$222K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,360 |
835 |
$182K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,755 |
660 |
$164K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,041 |
672 |
$107K |
| D0330 |
Panoramic radiographic image |
1,713 |
1,713 |
$100K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,115 |
2,115 |
$96K |
| D2950 |
|
457 |
395 |
$83K |
| D1110 |
Prophylaxis - adult |
1,152 |
1,152 |
$65K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
382 |
290 |
$61K |
| D4341 |
|
374 |
114 |
$56K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
65 |
63 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,505 |
1,505 |
$41K |
| D0140 |
Limited oral evaluation - problem focused |
787 |
785 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
2,511 |
2,448 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,116 |
1,116 |
$31K |
| D1120 |
Prophylaxis - child |
735 |
735 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,101 |
1,940 |
$29K |
| D4346 |
|
268 |
268 |
$19K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
104 |
80 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
527 |
527 |
$16K |
| D2331 |
|
128 |
92 |
$14K |
| D2330 |
|
95 |
60 |
$9K |
| D3320 |
|
13 |
12 |
$7K |
| D3310 |
|
15 |
13 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
518 |
159 |
$7K |
| D0272 |
Bitewings - two radiographic images |
278 |
278 |
$5K |
| D4910 |
|
28 |
28 |
$3K |
| D2332 |
|
20 |
16 |
$3K |
| D1354 |
|
94 |
29 |
$3K |