| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
328 |
179 |
$165K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,489 |
334 |
$95K |
| D0330 |
Panoramic radiographic image |
624 |
591 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
671 |
632 |
$19K |
| D1110 |
Prophylaxis - adult |
251 |
235 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
252 |
236 |
$5K |
| D0274 |
Bitewings - four radiographic images |
242 |
227 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
129 |
112 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
27 |
$634.40 |