| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
378 |
237 |
$180K |
| D1110 |
Prophylaxis - adult |
1,141 |
1,137 |
$102K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,522 |
1,515 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
953 |
950 |
$77K |
| D4910 |
|
992 |
985 |
$76K |
| D4341 |
|
1,016 |
280 |
$71K |
| D0210 |
Intraoral - complete series of radiographic images |
1,161 |
1,156 |
$55K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
453 |
190 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,094 |
1,441 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,755 |
1,747 |
$25K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
207 |
125 |
$24K |
| D1120 |
Prophylaxis - child |
521 |
521 |
$24K |
| D2954 |
|
220 |
144 |
$23K |
| D2140 |
|
244 |
98 |
$13K |
| D0274 |
Bitewings - four radiographic images |
645 |
643 |
$13K |
| D0330 |
Panoramic radiographic image |
419 |
419 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
166 |
77 |
$9K |
| D3310 |
|
22 |
14 |
$7K |
| D3320 |
|
16 |
12 |
$6K |
| D2330 |
|
31 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
15 |
$2K |
| D9430 |
|
50 |
50 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$156.00 |