| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
66 |
28 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
126 |
111 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
17 |
$2K |
| D0274 |
Bitewings - four radiographic images |
85 |
80 |
$2K |
| D0330 |
Panoramic radiographic image |
120 |
117 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
158 |
142 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
126 |
109 |
$1K |
| D1110 |
Prophylaxis - adult |
19 |
15 |
$730.12 |
| D1206 |
Topical application of fluoride varnish |
25 |
17 |
$423.94 |
| D0801 |
|
59 |
55 |
$0.00 |
| D0350 |
|
198 |
95 |
$0.00 |