| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
118 |
83 |
$69K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
252 |
152 |
$33K |
| D1110 |
Prophylaxis - adult |
438 |
436 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
460 |
460 |
$20K |
| D0274 |
Bitewings - four radiographic images |
475 |
475 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
434 |
433 |
$12K |
| D0330 |
Panoramic radiographic image |
187 |
187 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
755 |
743 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
231 |
225 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
496 |
496 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
29 |
12 |
$4K |
| D2950 |
|
29 |
25 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
224 |
224 |
$4K |
| D0350 |
|
28 |
28 |
$3K |
| D1120 |
Prophylaxis - child |
29 |
29 |
$911.47 |
| D1206 |
Topical application of fluoride varnish |
32 |
32 |
$566.92 |