| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,395 |
1,388 |
$88K |
| D1110 |
Prophylaxis - adult |
853 |
853 |
$74K |
| D0210 |
Intraoral - complete series of radiographic images |
1,020 |
1,014 |
$48K |
| D2740 |
Crown - porcelain/ceramic |
40 |
31 |
$19K |
| D4910 |
|
220 |
220 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
63 |
63 |
$4K |
| D9430 |
|
119 |
115 |
$3K |
| D4341 |
|
45 |
12 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
164 |
164 |
$2K |
| D0274 |
Bitewings - four radiographic images |
67 |
67 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
215 |
120 |
$777.42 |