| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
51 |
38 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
163 |
162 |
$10K |
| D1110 |
Prophylaxis - adult |
207 |
207 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
157 |
157 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
142 |
142 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
39 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
47 |
47 |
$762.68 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$470.30 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$420.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
12 |
$118.25 |