| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2950 |
|
271 |
205 |
$42K |
| D2740 |
Crown - porcelain/ceramic |
54 |
39 |
$32K |
| D1110 |
Prophylaxis - adult |
548 |
548 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
533 |
533 |
$23K |
| D0274 |
Bitewings - four radiographic images |
511 |
511 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
828 |
794 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
307 |
299 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,009 |
713 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
77 |
41 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
298 |
298 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
25 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
25 |
$4K |
| D1206 |
Topical application of fluoride varnish |
141 |
141 |
$4K |
| D0330 |
Panoramic radiographic image |
41 |
40 |
$3K |
| D1120 |
Prophylaxis - child |
53 |
53 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$854.32 |