| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
269 |
269 |
$15K |
| D2740 |
Crown - porcelain/ceramic |
15 |
12 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
152 |
152 |
$4K |
| D2950 |
|
16 |
13 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
169 |
163 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
43 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
46 |
46 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
89 |
82 |
$822.87 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$532.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$427.04 |