| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
357 |
230 |
$169K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
642 |
631 |
$41K |
| D4341 |
|
512 |
137 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
653 |
636 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
451 |
442 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,367 |
601 |
$10K |
| D9430 |
|
283 |
243 |
$9K |
| D4910 |
|
66 |
66 |
$5K |
| D1120 |
Prophylaxis - child |
125 |
124 |
$5K |
| D0274 |
Bitewings - four radiographic images |
197 |
197 |
$4K |
| D1206 |
Topical application of fluoride varnish |
29 |
29 |
$448.00 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$180.00 |