| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
559 |
285 |
$380K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
196 |
166 |
$146K |
| D2950 |
|
515 |
326 |
$84K |
| D3320 |
|
59 |
48 |
$33K |
| D1110 |
Prophylaxis - adult |
575 |
563 |
$32K |
| D0274 |
Bitewings - four radiographic images |
434 |
426 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
330 |
316 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
497 |
488 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
123 |
121 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
554 |
526 |
$9K |
| D1120 |
Prophylaxis - child |
174 |
171 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
68 |
46 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
102 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
132 |
128 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
301 |
285 |
$4K |
| D1351 |
Sealant - per tooth |
67 |
12 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
30 |
30 |
$840.00 |