| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0350 |
|
227 |
226 |
$45K |
| D2740 |
Crown - porcelain/ceramic |
27 |
15 |
$13K |
| D1110 |
Prophylaxis - adult |
161 |
161 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
174 |
174 |
$9K |
| D0383 |
|
56 |
56 |
$8K |
| D0274 |
Bitewings - four radiographic images |
201 |
201 |
$6K |
| D0330 |
Panoramic radiographic image |
106 |
106 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
121 |
121 |
$4K |
| D2950 |
|
26 |
14 |
$3K |
| D4910 |
|
13 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
30 |
30 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
26 |
$832.23 |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
41 |
$541.35 |