| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
36 |
29 |
$12K |
| D1110 |
Prophylaxis - adult |
255 |
253 |
$10K |
| D0330 |
Panoramic radiographic image |
177 |
169 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
159 |
158 |
$4K |
| D1351 |
Sealant - per tooth |
101 |
15 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
32 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
147 |
145 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
216 |
207 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
68 |
66 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
74 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
196 |
119 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
43 |
25 |
$979.10 |
| D4910 |
|
13 |
13 |
$808.00 |
| D4355 |
|
15 |
13 |
$803.43 |
| D1120 |
Prophylaxis - child |
15 |
15 |
$705.45 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$390.00 |