| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
298 |
259 |
$120K |
| D1110 |
Prophylaxis - adult |
1,043 |
1,040 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,309 |
1,305 |
$29K |
| D1120 |
Prophylaxis - child |
534 |
533 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
634 |
619 |
$20K |
| D2950 |
|
201 |
180 |
$19K |
| D0274 |
Bitewings - four radiographic images |
583 |
583 |
$15K |
| D1206 |
Topical application of fluoride varnish |
541 |
539 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,106 |
1,087 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
223 |
222 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
316 |
316 |
$11K |
| D4342 |
|
103 |
47 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,178 |
659 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
117 |
117 |
$3K |
| D4910 |
|
25 |
25 |
$995.44 |
| D4355 |
|
12 |
12 |
$583.75 |