| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,166 |
1,164 |
$103K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,257 |
1,253 |
$82K |
| D0120 |
Periodic oral evaluation - established patient |
742 |
741 |
$58K |
| D9430 |
|
1,394 |
1,216 |
$45K |
| D0210 |
Intraoral - complete series of radiographic images |
883 |
879 |
$42K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
80 |
60 |
$38K |
| D1206 |
Topical application of fluoride varnish |
921 |
918 |
$15K |
| D0274 |
Bitewings - four radiographic images |
534 |
534 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
621 |
620 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,065 |
978 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
440 |
432 |
$5K |
| D1120 |
Prophylaxis - child |
84 |
84 |
$4K |
| D0350 |
|
69 |
49 |
$643.20 |