| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
155 |
155 |
$13K |
| D2740 |
Crown - porcelain/ceramic |
15 |
13 |
$7K |
| D1206 |
Topical application of fluoride varnish |
371 |
371 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
108 |
108 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
32 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
44 |
44 |
$636.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$324.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
27 |
25 |
$133.65 |