| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
108 |
74 |
$59K |
| D0210 |
Intraoral - complete series of radiographic images |
354 |
344 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
230 |
116 |
$17K |
| D1110 |
Prophylaxis - adult |
330 |
321 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
430 |
416 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
119 |
60 |
$7K |
| D1206 |
Topical application of fluoride varnish |
285 |
278 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
124 |
122 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
109 |
106 |
$1K |
| D2950 |
|
54 |
44 |
$798.42 |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$778.25 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
29 |
$638.80 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$285.60 |