| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
505 |
358 |
$236K |
| D1110 |
Prophylaxis - adult |
1,115 |
1,113 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,508 |
1,506 |
$98K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,425 |
734 |
$95K |
| D0210 |
Intraoral - complete series of radiographic images |
1,227 |
1,226 |
$59K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
657 |
423 |
$52K |
| D1206 |
Topical application of fluoride varnish |
1,771 |
1,769 |
$39K |
| D4341 |
|
493 |
191 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
599 |
285 |
$32K |
| D1120 |
Prophylaxis - child |
554 |
554 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
390 |
390 |
$21K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
42 |
38 |
$19K |
| D9430 |
|
502 |
474 |
$16K |
| D0350 |
|
1,471 |
523 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,436 |
733 |
$14K |
| D2952 |
|
95 |
68 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
58 |
25 |
$7K |
| D0274 |
Bitewings - four radiographic images |
296 |
296 |
$6K |
| D4910 |
|
59 |
59 |
$6K |
| D3320 |
|
15 |
13 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
258 |
253 |
$3K |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$480.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$360.00 |