| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
360 |
360 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
207 |
206 |
$7K |
| D4341 |
|
37 |
13 |
$6K |
| D2740 |
Crown - porcelain/ceramic |
20 |
12 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
48 |
24 |
$4K |
| D1120 |
Prophylaxis - child |
104 |
104 |
$4K |
| D0330 |
Panoramic radiographic image |
130 |
130 |
$3K |
| D1110 |
Prophylaxis - adult |
49 |
49 |
$2K |
| D1206 |
Topical application of fluoride varnish |
76 |
76 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$439.76 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$327.60 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$152.03 |