| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,546 |
1,542 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,623 |
1,618 |
$37K |
| D0330 |
Panoramic radiographic image |
500 |
500 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
549 |
549 |
$21K |
| D2740 |
Crown - porcelain/ceramic |
33 |
28 |
$14K |
| D0274 |
Bitewings - four radiographic images |
276 |
276 |
$8K |
| D1206 |
Topical application of fluoride varnish |
275 |
273 |
$5K |
| D2950 |
|
16 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$1K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$875.19 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$874.21 |