| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
420 |
406 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
141 |
135 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
216 |
202 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
404 |
401 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
50 |
25 |
$3K |
| D0274 |
Bitewings - four radiographic images |
75 |
75 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
281 |
248 |
$421.37 |
| D9610 |
|
221 |
208 |
$387.45 |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
29 |
$210.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
95 |
92 |
$0.00 |
| D9994 |
|
13 |
13 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
31 |
16 |
$0.00 |
| D4910 |
|
37 |
37 |
$0.00 |
| D2950 |
|
57 |
27 |
$0.00 |