| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
482 |
127 |
$164K |
| D2950 |
|
407 |
105 |
$54K |
| D0220 |
Intraoral - periapical first radiographic image |
1,783 |
1,546 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
480 |
457 |
$22K |
| D0367 |
|
141 |
131 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
445 |
418 |
$14K |
| D1120 |
Prophylaxis - child |
268 |
259 |
$13K |
| D1110 |
Prophylaxis - adult |
122 |
118 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
473 |
464 |
$12K |
| D1206 |
Topical application of fluoride varnish |
495 |
480 |
$11K |
| D0274 |
Bitewings - four radiographic images |
566 |
543 |
$10K |
| D1351 |
Sealant - per tooth |
398 |
56 |
$9K |
| D0330 |
Panoramic radiographic image |
376 |
346 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,330 |
1,031 |
$7K |
| D9215 |
|
269 |
237 |
$1K |
| D9630 |
|
13 |
13 |
$480.00 |