| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
333 |
206 |
$158K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,025 |
2,018 |
$129K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,419 |
875 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
1,419 |
1,417 |
$69K |
| D1110 |
Prophylaxis - adult |
710 |
710 |
$60K |
| D1120 |
Prophylaxis - child |
1,355 |
1,355 |
$49K |
| D0210 |
Intraoral - complete series of radiographic images |
886 |
883 |
$41K |
| D0330 |
Panoramic radiographic image |
1,040 |
1,038 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
298 |
154 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
183 |
121 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
652 |
652 |
$7K |
| D0272 |
Bitewings - two radiographic images |
318 |
318 |
$4K |
| D3221 |
|
51 |
49 |
$3K |