| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
58 |
27 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
713 |
645 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,987 |
550 |
$8K |
| D2950 |
|
47 |
25 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
73 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
144 |
143 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
13 |
$1K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$728.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$630.00 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$351.00 |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$253.50 |
| D1330 |
|
26 |
26 |
$0.00 |