| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
75 |
46 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
343 |
341 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
204 |
93 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
283 |
282 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
234 |
70 |
$12K |
| D9430 |
|
336 |
297 |
$11K |
| D0350 |
|
786 |
193 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
76 |
44 |
$6K |
| D2952 |
|
40 |
32 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
792 |
250 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
49 |
44 |
$2K |
| D0330 |
Panoramic radiographic image |
58 |
57 |
$2K |
| D1206 |
Topical application of fluoride varnish |
48 |
48 |
$754.50 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$577.50 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$252.00 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$172.80 |
| D0270 |
|
25 |
25 |
$125.00 |