| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
735 |
453 |
$377K |
| D2954 |
|
999 |
556 |
$109K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,254 |
1,253 |
$63K |
| D1110 |
Prophylaxis - adult |
723 |
720 |
$56K |
| D0210 |
Intraoral - complete series of radiographic images |
674 |
672 |
$35K |
| D6740 |
|
54 |
14 |
$24K |
| D4341 |
|
299 |
81 |
$19K |
| D9430 |
|
452 |
425 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
229 |
109 |
$14K |
| D9110 |
|
205 |
203 |
$13K |
| D6245 |
|
27 |
14 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
276 |
276 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
784 |
780 |
$10K |
| D0330 |
Panoramic radiographic image |
156 |
156 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
312 |
311 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
27 |
$2K |
| D4910 |
|
26 |
26 |
$2K |
| D0274 |
Bitewings - four radiographic images |
68 |
68 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
122 |
81 |
$538.95 |