| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9110 |
|
744 |
472 |
$47K |
| D9430 |
|
1,007 |
702 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
213 |
208 |
$12K |
| D2740 |
Crown - porcelain/ceramic |
24 |
19 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
873 |
599 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
211 |
205 |
$9K |
| D2954 |
|
76 |
43 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,005 |
591 |
$4K |
| D1206 |
Topical application of fluoride varnish |
260 |
260 |
$4K |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$4K |
| D2931 |
|
26 |
12 |
$3K |
| D4341 |
|
45 |
12 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
24 |
24 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
57 |
53 |
$461.00 |