| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0350 |
|
4,667 |
1,142 |
$40K |
| D1110 |
Prophylaxis - adult |
312 |
312 |
$28K |
| D4910 |
|
283 |
283 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
278 |
277 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
180 |
179 |
$14K |
| D9430 |
|
329 |
280 |
$10K |
| D2740 |
Crown - porcelain/ceramic |
22 |
13 |
$10K |
| D1206 |
Topical application of fluoride varnish |
581 |
579 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,372 |
654 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
192 |
192 |
$9K |
| D0274 |
Bitewings - four radiographic images |
312 |
312 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
176 |
167 |
$2K |
| D2954 |
|
19 |
14 |
$2K |