| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,749 |
3,729 |
$302K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,874 |
3,845 |
$236K |
| D0120 |
Periodic oral evaluation - established patient |
3,675 |
3,659 |
$203K |
| D0230 |
Intraoral - periapical each additional radiographic image |
33,630 |
6,267 |
$136K |
| D1120 |
Prophylaxis - child |
2,723 |
2,709 |
$104K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,810 |
6,773 |
$86K |
| D0274 |
Bitewings - four radiographic images |
3,942 |
3,926 |
$82K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
145 |
98 |
$54K |
| D7140 |
Extraction, erupted tooth or exposed root |
862 |
532 |
$47K |
| D9430 |
|
989 |
962 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
2,465 |
2,431 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
542 |
541 |
$24K |
| D4341 |
|
306 |
88 |
$20K |
| D0330 |
Panoramic radiographic image |
359 |
354 |
$10K |
| D1351 |
Sealant - per tooth |
104 |
15 |
$4K |
| D0350 |
|
124 |
50 |
$1K |