| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4381 |
|
582 |
51 |
$48K |
| D2740 |
Crown - porcelain/ceramic |
58 |
26 |
$39K |
| D1110 |
Prophylaxis - adult |
258 |
222 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
164 |
139 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
252 |
239 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
171 |
147 |
$3K |
| D1330 |
|
118 |
118 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
42 |
42 |
$1K |
| D1206 |
Topical application of fluoride varnish |
24 |
24 |
$936.00 |
| D4910 |
|
12 |
12 |
$900.00 |
| D0274 |
Bitewings - four radiographic images |
23 |
13 |
$99.00 |