| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
677 |
401 |
$317K |
| D0120 |
Periodic oral evaluation - established patient |
2,488 |
2,481 |
$134K |
| D1110 |
Prophylaxis - adult |
1,152 |
1,147 |
$99K |
| D0230 |
Intraoral - periapical each additional radiographic image |
21,342 |
3,815 |
$87K |
| D1120 |
Prophylaxis - child |
2,041 |
2,037 |
$76K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,118 |
1,115 |
$70K |
| D2140 |
|
778 |
279 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,436 |
3,422 |
$42K |
| D0272 |
Bitewings - two radiographic images |
3,480 |
3,469 |
$41K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
81 |
68 |
$38K |
| D0350 |
|
2,702 |
917 |
$26K |
| D2954 |
|
203 |
140 |
$21K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
170 |
87 |
$11K |
| D3320 |
|
16 |
13 |
$6K |
| D9430 |
|
177 |
172 |
$6K |
| D1351 |
Sealant - per tooth |
108 |
28 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
174 |
170 |
$2K |
| D4910 |
|
25 |
25 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
13 |
$2K |