| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
71 |
52 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
309 |
304 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
196 |
196 |
$9K |
| D4910 |
|
100 |
100 |
$8K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
16 |
13 |
$8K |
| D0350 |
|
671 |
230 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
103 |
44 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
36 |
$4K |
| D1320 |
|
217 |
217 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
74 |
74 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$980.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$682.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
127 |
38 |
$526.50 |