| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,408 |
1,395 |
$79K |
| D4910 |
|
1,053 |
1,024 |
$79K |
| D1110 |
Prophylaxis - adult |
845 |
836 |
$70K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
972 |
966 |
$62K |
| D1120 |
Prophylaxis - child |
1,223 |
1,217 |
$39K |
| D4341 |
|
504 |
144 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
691 |
687 |
$31K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
52 |
30 |
$25K |
| D0274 |
Bitewings - four radiographic images |
962 |
952 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,225 |
1,220 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,048 |
1,603 |
$12K |
| D0350 |
|
492 |
256 |
$5K |
| D4342 |
|
39 |
17 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
85 |
80 |
$1K |
| D9430 |
|
16 |
14 |
$512.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$185.50 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$165.00 |