| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
64 |
54 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
493 |
165 |
$25K |
| D1110 |
Prophylaxis - adult |
444 |
443 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
409 |
406 |
$11K |
| D5110 |
|
15 |
15 |
$9K |
| D0274 |
Bitewings - four radiographic images |
312 |
311 |
$7K |
| D0330 |
Panoramic radiographic image |
236 |
236 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
367 |
365 |
$7K |
| D5225 |
|
12 |
12 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
648 |
628 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
202 |
201 |
$5K |
| D1206 |
Topical application of fluoride varnish |
265 |
265 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
292 |
200 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
15 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
35 |
35 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$172.00 |