| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
80 |
46 |
$57K |
| D1110 |
Prophylaxis - adult |
1,418 |
1,415 |
$51K |
| D0140 |
Limited oral evaluation - problem focused |
1,297 |
1,269 |
$36K |
| D4341 |
|
194 |
68 |
$30K |
| D0274 |
Bitewings - four radiographic images |
813 |
810 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
938 |
935 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
626 |
624 |
$17K |
| D0330 |
Panoramic radiographic image |
629 |
626 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,407 |
1,374 |
$14K |
| D1120 |
Prophylaxis - child |
138 |
138 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
785 |
748 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
171 |
171 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
30 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
24 |
$4K |
| D2950 |
|
17 |
16 |
$3K |