| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
37 |
14 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
785 |
783 |
$18K |
| D4341 |
|
107 |
32 |
$17K |
| D2950 |
|
40 |
16 |
$7K |
| D1110 |
Prophylaxis - adult |
169 |
169 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
110 |
110 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
144 |
144 |
$5K |
| D1120 |
Prophylaxis - child |
70 |
70 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
12 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
103 |
103 |
$2K |
| D4355 |
|
38 |
37 |
$2K |
| D1351 |
Sealant - per tooth |
68 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
51 |
51 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
53 |
52 |
$578.67 |
| D1999 |
|
404 |
358 |
$0.00 |