| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
14,634 |
14,633 |
$664K |
| D0120 |
Periodic oral evaluation - established patient |
16,485 |
16,482 |
$374K |
| D0274 |
Bitewings - four radiographic images |
14,435 |
14,433 |
$314K |
| D0220 |
Intraoral - periapical first radiographic image |
19,214 |
19,070 |
$205K |
| D0230 |
Intraoral - periapical each additional radiographic image |
17,165 |
17,110 |
$111K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
86 |
49 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,666 |
2,666 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
225 |
136 |
$13K |
| D9110 |
|
493 |
483 |
$9K |
| D1120 |
Prophylaxis - child |
181 |
181 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
25 |
$2K |
| D2954 |
|
19 |
12 |
$2K |
| D9310 |
|
12 |
12 |
$720.66 |
| D0140 |
Limited oral evaluation - problem focused |
40 |
40 |
$430.22 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$372.48 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$138.76 |