| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,015 |
1,012 |
$89K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
929 |
928 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
480 |
476 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
755 |
754 |
$36K |
| D2740 |
Crown - porcelain/ceramic |
71 |
26 |
$34K |
| D4341 |
|
400 |
106 |
$28K |
| D1206 |
Topical application of fluoride varnish |
763 |
760 |
$13K |
| D4910 |
|
164 |
164 |
$12K |
| D0274 |
Bitewings - four radiographic images |
441 |
438 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
609 |
609 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,653 |
573 |
$7K |
| D1120 |
Prophylaxis - child |
103 |
103 |
$4K |
| D9430 |
|
129 |
119 |
$4K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$168.00 |