| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
92 |
59 |
$64K |
| D1110 |
Prophylaxis - adult |
693 |
675 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
612 |
599 |
$14K |
| D2335 |
|
40 |
14 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
86 |
79 |
$6K |
| D2394 |
|
44 |
12 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
93 |
89 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
180 |
180 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
48 |
$2K |
| D0274 |
Bitewings - four radiographic images |
62 |
62 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
99 |
74 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$806.00 |