| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
370 |
214 |
$250K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,072 |
526 |
$112K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
751 |
462 |
$102K |
| D0350 |
|
636 |
569 |
$93K |
| D0330 |
Panoramic radiographic image |
1,416 |
1,415 |
$75K |
| D1110 |
Prophylaxis - adult |
1,340 |
1,334 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,308 |
1,307 |
$55K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
277 |
113 |
$46K |
| D2950 |
|
329 |
215 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,298 |
1,294 |
$39K |
| D0140 |
Limited oral evaluation - problem focused |
921 |
887 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,143 |
1,136 |
$30K |
| D0460 |
|
383 |
382 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
54 |
40 |
$9K |
| D2394 |
|
39 |
25 |
$8K |
| D1206 |
Topical application of fluoride varnish |
367 |
367 |
$7K |
| D4342 |
|
49 |
14 |
$4K |
| D1120 |
Prophylaxis - child |
101 |
101 |
$4K |
| D4910 |
|
30 |
29 |
$3K |
| D2330 |
|
17 |
12 |
$2K |
| D0380 |
|
12 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
81 |
81 |
$1K |