| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
256 |
148 |
$141K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
667 |
139 |
$87K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
426 |
237 |
$33K |
| D0330 |
Panoramic radiographic image |
441 |
434 |
$22K |
| D1110 |
Prophylaxis - adult |
312 |
306 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
433 |
428 |
$13K |
| D1206 |
Topical application of fluoride varnish |
545 |
540 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
131 |
82 |
$12K |
| D0274 |
Bitewings - four radiographic images |
396 |
389 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
440 |
433 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
890 |
433 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
607 |
589 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
97 |
16 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
216 |
213 |
$5K |
| D4355 |
|
31 |
31 |
$3K |
| D2950 |
|
75 |
53 |
$2K |