| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
299 |
154 |
$206K |
| D1110 |
Prophylaxis - adult |
1,039 |
987 |
$54K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
68 |
59 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
954 |
920 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,157 |
1,097 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,262 |
1,599 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
2,128 |
2,000 |
$28K |
| D2954 |
|
162 |
94 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
964 |
921 |
$26K |
| D1120 |
Prophylaxis - child |
479 |
454 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
297 |
135 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
931 |
881 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
410 |
379 |
$15K |
| D0272 |
Bitewings - two radiographic images |
98 |
95 |
$3K |
| D1351 |
Sealant - per tooth |
51 |
14 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$940.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$690.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$428.00 |
| D0270 |
|
14 |
14 |
$142.00 |