| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
85 |
38 |
$40K |
| D1110 |
Prophylaxis - adult |
345 |
345 |
$30K |
| D4910 |
|
380 |
378 |
$29K |
| D2952 |
|
126 |
66 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,708 |
477 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
89 |
88 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
102 |
102 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
79 |
39 |
$6K |
| D0250 |
|
286 |
256 |
$6K |
| D1206 |
Topical application of fluoride varnish |
358 |
358 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
434 |
417 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
76 |
76 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
99 |
99 |
$1K |
| D9430 |
|
29 |
27 |
$928.00 |
| D0350 |
|
18 |
12 |
$192.00 |