| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D5110 |
|
16 |
14 |
$7K |
| D1110 |
Prophylaxis - adult |
219 |
210 |
$7K |
| D2740 |
Crown - porcelain/ceramic |
30 |
12 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
156 |
125 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
195 |
182 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
222 |
213 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
68 |
68 |
$1K |
| D0330 |
Panoramic radiographic image |
86 |
83 |
$751.55 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$317.17 |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
41 |
$222.99 |
| D0274 |
Bitewings - four radiographic images |
32 |
32 |
$122.85 |