| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
694 |
692 |
$33K |
| D2740 |
Crown - porcelain/ceramic |
19 |
13 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
662 |
662 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
152 |
150 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
108 |
108 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
284 |
279 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$3K |
| D2950 |
|
16 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
63 |
63 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$955.32 |