| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,225 |
2,211 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
2,555 |
2,545 |
$75K |
| D1206 |
Topical application of fluoride varnish |
665 |
661 |
$21K |
| D1120 |
Prophylaxis - child |
375 |
375 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
1,148 |
1,119 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
280 |
277 |
$12K |
| D0274 |
Bitewings - four radiographic images |
1,040 |
1,028 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
215 |
214 |
$10K |
| D2740 |
Crown - porcelain/ceramic |
18 |
12 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
131 |
83 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,534 |
1,513 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
125 |
125 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
584 |
583 |
$2K |
| D0272 |
Bitewings - two radiographic images |
211 |
211 |
$2K |
| D0270 |
|
25 |
25 |
$125.00 |