| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
265 |
64 |
$24K |
| D2740 |
Crown - porcelain/ceramic |
42 |
16 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
333 |
281 |
$18K |
| D5214 |
|
28 |
20 |
$13K |
| D5110 |
|
20 |
17 |
$10K |
| D5120 |
|
21 |
18 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
344 |
293 |
$10K |
| D5213 |
|
19 |
15 |
$9K |
| D2950 |
|
77 |
21 |
$7K |
| D4342 |
|
38 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
42 |
37 |
$2K |
| D0274 |
Bitewings - four radiographic images |
37 |
32 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
66 |
55 |
$750.00 |
| D0120 |
Periodic oral evaluation - established patient |
37 |
32 |
$676.00 |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
32 |
$371.44 |
| D0230 |
Intraoral - periapical each additional radiographic image |
37 |
32 |
$331.24 |
| D0603 |
|
590 |
438 |
$0.00 |