| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
122 |
78 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
176 |
176 |
$7K |
| D2950 |
|
56 |
42 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
320 |
298 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
33 |
33 |
$2K |
| D1110 |
Prophylaxis - adult |
47 |
47 |
$2K |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
28 |
28 |
$719.70 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$560.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$336.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
26 |
$232.25 |
| D4341 |
|
28 |
12 |
$0.00 |