| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
464 |
462 |
$24K |
| D1110 |
Prophylaxis - adult |
146 |
145 |
$13K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
21 |
14 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
199 |
198 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
145 |
144 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
639 |
636 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,960 |
979 |
$8K |
| D0274 |
Bitewings - four radiographic images |
247 |
246 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
40 |
$4K |
| D1120 |
Prophylaxis - child |
74 |
74 |
$2K |
| D2954 |
|
16 |
12 |
$2K |
| D9430 |
|
24 |
24 |
$768.00 |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
39 |
$468.00 |