| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
35 |
25 |
$17K |
| D1110 |
Prophylaxis - adult |
364 |
364 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
107 |
66 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
265 |
262 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
376 |
375 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
110 |
109 |
$9K |
| D2950 |
|
35 |
25 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
330 |
318 |
$4K |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$2K |
| D0350 |
|
31 |
30 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
39 |
$541.85 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$426.53 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$231.70 |