| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
67 |
65 |
$39K |
| D1110 |
Prophylaxis - adult |
87 |
87 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
34 |
$4K |
| D2954 |
|
28 |
27 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
105 |
105 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
78 |
78 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
70 |
70 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
95 |
95 |
$1K |
| D0350 |
|
89 |
89 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
53 |
$742.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
37 |
37 |
$446.32 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$415.86 |
| D0270 |
|
30 |
30 |
$395.64 |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
18 |
$252.00 |