| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
387 |
380 |
$5K |
| D0274 |
Bitewings - four radiographic images |
155 |
150 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
286 |
281 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
135 |
123 |
$963.39 |
| D0220 |
Intraoral - periapical first radiographic image |
156 |
150 |
$900.86 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
181 |
178 |
$651.20 |
| D1206 |
Topical application of fluoride varnish |
124 |
124 |
$486.54 |
| D0230 |
Intraoral - periapical each additional radiographic image |
40 |
40 |
$406.84 |
| D2740 |
Crown - porcelain/ceramic |
98 |
67 |
$0.00 |
| D2950 |
|
18 |
13 |
$0.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
102 |
43 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$0.00 |