| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
42 |
27 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
276 |
276 |
$8K |
| D1110 |
Prophylaxis - adult |
132 |
132 |
$7K |
| D1120 |
Prophylaxis - child |
155 |
155 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
182 |
182 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
163 |
160 |
$3K |
| D0274 |
Bitewings - four radiographic images |
58 |
58 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
103 |
84 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
19 |
19 |
$864.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$371.00 |