| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
925 |
530 |
$471K |
| D2950 |
|
887 |
564 |
$118K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
529 |
192 |
$65K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
615 |
410 |
$64K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
312 |
222 |
$38K |
| D1110 |
Prophylaxis - adult |
729 |
727 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,134 |
1,132 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
756 |
752 |
$28K |
| D1120 |
Prophylaxis - child |
723 |
722 |
$28K |
| D4341 |
|
318 |
110 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
439 |
436 |
$27K |
| D1206 |
Topical application of fluoride varnish |
922 |
922 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
588 |
575 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,369 |
1,311 |
$20K |
| D0274 |
Bitewings - four radiographic images |
391 |
390 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
846 |
582 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
86 |
66 |
$7K |
| D1351 |
Sealant - per tooth |
196 |
27 |
$6K |
| D0330 |
Panoramic radiographic image |
44 |
43 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
66 |
66 |
$1K |
| D4910 |
|
13 |
13 |
$909.00 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$596.68 |