| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
946 |
943 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,396 |
1,393 |
$34K |
| D1120 |
Prophylaxis - child |
384 |
384 |
$14K |
| D2740 |
Crown - porcelain/ceramic |
17 |
15 |
$11K |
| D1206 |
Topical application of fluoride varnish |
221 |
221 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
130 |
130 |
$5K |
| D0274 |
Bitewings - four radiographic images |
167 |
167 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
100 |
99 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$1K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$252.50 |