| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
751 |
750 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
533 |
532 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
591 |
590 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
604 |
604 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,651 |
1,339 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
433 |
311 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,433 |
1,430 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
280 |
228 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,187 |
1,130 |
$14K |
| D1120 |
Prophylaxis - child |
160 |
159 |
$7K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
14 |
13 |
$7K |
| D0272 |
Bitewings - two radiographic images |
218 |
217 |
$3K |
| D2331 |
|
15 |
13 |
$1K |
| D9430 |
|
13 |
13 |
$416.00 |
| D1999 |
|
53 |
52 |
$0.00 |