| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,168 |
1,168 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,111 |
1,110 |
$25K |
| D0274 |
Bitewings - four radiographic images |
920 |
920 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,385 |
1,377 |
$15K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
13 |
13 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,143 |
1,143 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
51 |
51 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
170 |
170 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$1K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$165.36 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$136.11 |