| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
50 |
30 |
$38K |
| D1110 |
Prophylaxis - adult |
285 |
283 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
271 |
268 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
139 |
$7K |
| D0274 |
Bitewings - four radiographic images |
197 |
195 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
32 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
160 |
159 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
34 |
32 |
$3K |
| D2950 |
|
23 |
17 |
$3K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$2K |
| D0350 |
|
79 |
79 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
191 |
81 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
159 |
151 |
$2K |
| D1120 |
Prophylaxis - child |
17 |
17 |
$613.30 |
| D1206 |
Topical application of fluoride varnish |
21 |
21 |
$560.12 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$517.80 |