| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
31 |
13 |
$22K |
| D1110 |
Prophylaxis - adult |
278 |
278 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
106 |
57 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
223 |
223 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
510 |
484 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
122 |
120 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
233 |
233 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
142 |
139 |
$6K |
| D0274 |
Bitewings - four radiographic images |
149 |
149 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
354 |
247 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
24 |
$3K |
| D1206 |
Topical application of fluoride varnish |
98 |
98 |
$2K |
| D1120 |
Prophylaxis - child |
59 |
59 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$324.00 |
| D0350 |
|
90 |
89 |
$0.00 |