| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
491 |
155 |
$338K |
| D1110 |
Prophylaxis - adult |
868 |
861 |
$46K |
| D2950 |
|
103 |
37 |
$17K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
22 |
15 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
687 |
683 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
232 |
229 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
462 |
407 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
68 |
34 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
43 |
13 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
17 |
$3K |
| D1206 |
Topical application of fluoride varnish |
119 |
118 |
$3K |
| D1120 |
Prophylaxis - child |
52 |
52 |
$3K |
| D2394 |
|
28 |
12 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
22 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$1K |