| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
439 |
104 |
$216K |
| D1110 |
Prophylaxis - adult |
318 |
318 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
231 |
231 |
$6K |
| D0274 |
Bitewings - four radiographic images |
218 |
218 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
170 |
170 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
104 |
28 |
$5K |
| D1120 |
Prophylaxis - child |
75 |
75 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
20 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
157 |
157 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
131 |
131 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
88 |
88 |
$1K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
142 |
142 |
$672.10 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$255.68 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$220.00 |