| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
311 |
311 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
265 |
265 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
177 |
177 |
$14K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
28 |
27 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
760 |
758 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
167 |
167 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
64 |
29 |
$7K |
| D4910 |
|
90 |
90 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
382 |
263 |
$6K |
| D0274 |
Bitewings - four radiographic images |
143 |
143 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
96 |
89 |
$1K |
| D9430 |
|
28 |
24 |
$896.00 |
| D1120 |
Prophylaxis - child |
16 |
16 |
$787.50 |