| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
545 |
321 |
$215K |
| D2752 |
|
197 |
110 |
$74K |
| D1110 |
Prophylaxis - adult |
873 |
870 |
$57K |
| D0140 |
Limited oral evaluation - problem focused |
961 |
932 |
$45K |
| D0330 |
Panoramic radiographic image |
916 |
910 |
$42K |
| D7140 |
Extraction, erupted tooth or exposed root |
225 |
128 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
446 |
444 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,434 |
1,429 |
$23K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
29 |
26 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
592 |
592 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,332 |
1,196 |
$15K |
| D2950 |
|
163 |
113 |
$14K |
| D1351 |
Sealant - per tooth |
224 |
27 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
295 |
294 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
25 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
13 |
$3K |
| D1120 |
Prophylaxis - child |
40 |
40 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
171 |
159 |
$1K |
| D1330 |
|
13 |
13 |
$93.60 |