| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
837 |
772 |
$42K |
| D0274 |
Bitewings - four radiographic images |
571 |
515 |
$19K |
| D2740 |
Crown - porcelain/ceramic |
19 |
13 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
856 |
788 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
718 |
633 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
434 |
379 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
113 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
43 |
42 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
12 |
$372.00 |