| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
957 |
949 |
$85K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
813 |
808 |
$53K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
88 |
60 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
459 |
454 |
$40K |
| D4910 |
|
275 |
268 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,769 |
919 |
$20K |
| D1206 |
Topical application of fluoride varnish |
956 |
948 |
$17K |
| D0274 |
Bitewings - four radiographic images |
544 |
540 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
194 |
193 |
$9K |
| D4341 |
|
96 |
26 |
$7K |
| D9430 |
|
102 |
100 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
248 |
239 |
$3K |