| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
997 |
996 |
$89K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,074 |
1,071 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
781 |
779 |
$61K |
| D0210 |
Intraoral - complete series of radiographic images |
743 |
743 |
$36K |
| D0274 |
Bitewings - four radiographic images |
798 |
794 |
$17K |
| D1206 |
Topical application of fluoride varnish |
954 |
953 |
$17K |
| D1120 |
Prophylaxis - child |
279 |
274 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,048 |
1,084 |
$8K |
| D9430 |
|
209 |
209 |
$7K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
14 |
13 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
203 |
200 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
25 |
$2K |
| D2952 |
|
15 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
124 |
124 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
14 |
$1K |