| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
316 |
161 |
$110K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
610 |
117 |
$97K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,537 |
1,802 |
$84K |
| D0330 |
Panoramic radiographic image |
1,055 |
879 |
$81K |
| D0274 |
Bitewings - four radiographic images |
1,631 |
1,296 |
$75K |
| D1110 |
Prophylaxis - adult |
1,015 |
874 |
$73K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
519 |
200 |
$69K |
| D0220 |
Intraoral - periapical first radiographic image |
3,350 |
2,559 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,099 |
893 |
$56K |
| D0140 |
Limited oral evaluation - problem focused |
817 |
639 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
965 |
788 |
$34K |
| D2950 |
|
182 |
120 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
149 |
68 |
$14K |
| D9243 |
|
29 |
12 |
$8K |
| D1206 |
Topical application of fluoride varnish |
143 |
120 |
$3K |
| D9239 |
|
23 |
12 |
$2K |
| D4910 |
|
14 |
13 |
$1K |
| D1120 |
Prophylaxis - child |
13 |
12 |
$779.40 |