| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,605 |
1,600 |
$106K |
| D1110 |
Prophylaxis - adult |
1,094 |
1,087 |
$97K |
| D0210 |
Intraoral - complete series of radiographic images |
1,455 |
1,448 |
$69K |
| D0350 |
|
7,396 |
1,950 |
$68K |
| D2740 |
Crown - porcelain/ceramic |
128 |
71 |
$60K |
| D4910 |
|
328 |
328 |
$25K |
| D1206 |
Topical application of fluoride varnish |
1,353 |
1,347 |
$23K |
| D0330 |
Panoramic radiographic image |
546 |
539 |
$16K |
| D4341 |
|
217 |
62 |
$15K |
| D2954 |
|
46 |
35 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
22 |
13 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
381 |
75 |
$1K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$682.50 |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$583.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$182.00 |