| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
298 |
180 |
$152K |
| D1110 |
Prophylaxis - adult |
1,879 |
1,879 |
$105K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,151 |
535 |
$104K |
| D0274 |
Bitewings - four radiographic images |
1,768 |
1,767 |
$50K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
539 |
251 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,451 |
1,451 |
$41K |
| D0330 |
Panoramic radiographic image |
590 |
590 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
722 |
722 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
1,089 |
1,084 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
551 |
545 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
281 |
280 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
104 |
39 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
271 |
271 |
$4K |
| D2140 |
|
69 |
39 |
$4K |
| D1120 |
Prophylaxis - child |
69 |
69 |
$3K |
| D2954 |
|
19 |
12 |
$3K |
| D2160 |
|
21 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
44 |
41 |
$350.95 |