| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
151 |
88 |
$104K |
| D1110 |
Prophylaxis - adult |
366 |
362 |
$20K |
| D2950 |
|
109 |
71 |
$18K |
| D0330 |
Panoramic radiographic image |
267 |
248 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
175 |
175 |
$8K |
| D0274 |
Bitewings - four radiographic images |
245 |
242 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
163 |
161 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
61 |
59 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
130 |
122 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$496.00 |