| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
507 |
269 |
$455K |
| D7140 |
Extraction, erupted tooth or exposed root |
5,682 |
1,443 |
$429K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,894 |
1,617 |
$244K |
| D0210 |
Intraoral - complete series of radiographic images |
2,252 |
2,122 |
$157K |
| D1110 |
Prophylaxis - adult |
3,416 |
3,229 |
$148K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,338 |
902 |
$135K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,043 |
2,909 |
$102K |
| D4342 |
|
960 |
275 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
4,005 |
3,786 |
$89K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
986 |
620 |
$78K |
| D0274 |
Bitewings - four radiographic images |
2,781 |
2,600 |
$72K |
| D1206 |
Topical application of fluoride varnish |
2,700 |
2,514 |
$52K |
| D0330 |
Panoramic radiographic image |
514 |
444 |
$46K |
| D1120 |
Prophylaxis - child |
1,501 |
1,419 |
$43K |
| D4341 |
|
224 |
68 |
$42K |
| D2331 |
|
348 |
222 |
$36K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
303 |
163 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,500 |
1,491 |
$25K |
| D5110 |
|
29 |
26 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
2,613 |
2,355 |
$20K |
| D1351 |
Sealant - per tooth |
547 |
134 |
$20K |
| D2332 |
|
127 |
66 |
$19K |
| D4910 |
|
328 |
293 |
$18K |
| D0350 |
|
645 |
613 |
$17K |
| D2950 |
|
90 |
73 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
371 |
352 |
$12K |
| D2335 |
|
61 |
36 |
$12K |
| D2394 |
|
50 |
33 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
97 |
41 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
148 |
147 |
$2K |
| D0272 |
Bitewings - two radiographic images |
160 |
151 |
$2K |
| D2160 |
|
19 |
12 |
$1K |
| D2330 |
|
15 |
14 |
$889.09 |