| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
21 |
12 |
$17K |
| D1110 |
Prophylaxis - adult |
210 |
210 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
205 |
205 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
77 |
76 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$995.04 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$212.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$104.40 |