| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
36 |
28 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
505 |
503 |
$13K |
| D1110 |
Prophylaxis - adult |
204 |
204 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
286 |
278 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
131 |
131 |
$3K |
| D1120 |
Prophylaxis - child |
71 |
71 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$2K |
| D2950 |
|
14 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
109 |
94 |
$936.19 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$419.03 |