| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
57 |
46 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
350 |
350 |
$23K |
| D1110 |
Prophylaxis - adult |
212 |
212 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
255 |
255 |
$12K |
| D9430 |
|
235 |
232 |
$7K |
| D4910 |
|
66 |
66 |
$5K |
| D1206 |
Topical application of fluoride varnish |
241 |
240 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
272 |
269 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
27 |
$3K |
| D4341 |
|
39 |
13 |
$3K |
| D1120 |
Prophylaxis - child |
47 |
47 |
$2K |
| D2954 |
|
17 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
60 |
60 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
228 |
116 |
$899.10 |
| D1208 |
Topical application of fluoride, excluding varnish |
42 |
42 |
$625.00 |