| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
146 |
83 |
$76K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
143 |
84 |
$75K |
| D1110 |
Prophylaxis - adult |
1,095 |
1,035 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
931 |
885 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
511 |
428 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
740 |
610 |
$9K |
| D0274 |
Bitewings - four radiographic images |
86 |
66 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
17 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
25 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$687.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$612.00 |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$448.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$350.00 |