| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
639 |
103 |
$394K |
| D1110 |
Prophylaxis - adult |
711 |
706 |
$31K |
| D2950 |
|
151 |
48 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
522 |
519 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
159 |
158 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
176 |
167 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
373 |
357 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
38 |
$2K |
| D0274 |
Bitewings - four radiographic images |
42 |
42 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
71 |
70 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
74 |
70 |
$657.77 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$408.00 |