| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
54 |
39 |
$32K |
| D1110 |
Prophylaxis - adult |
353 |
353 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
500 |
497 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
722 |
680 |
$12K |
| D2950 |
|
52 |
40 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
40 |
$8K |
| D1206 |
Topical application of fluoride varnish |
230 |
230 |
$6K |
| D1120 |
Prophylaxis - child |
80 |
80 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
235 |
219 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
44 |
41 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$908.75 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$431.25 |