| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,755 |
1,740 |
$150K |
| D0120 |
Periodic oral evaluation - established patient |
2,384 |
2,369 |
$140K |
| D0230 |
Intraoral - periapical each additional radiographic image |
17,627 |
3,676 |
$72K |
| D1120 |
Prophylaxis - child |
1,657 |
1,650 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
967 |
967 |
$59K |
| D0274 |
Bitewings - four radiographic images |
2,077 |
2,067 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,448 |
3,434 |
$43K |
| D4910 |
|
526 |
526 |
$40K |
| D9430 |
|
1,068 |
946 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
2,279 |
2,198 |
$27K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
31 |
27 |
$15K |
| D0330 |
Panoramic radiographic image |
330 |
329 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
25 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
79 |
79 |
$886.00 |
| D1320 |
|
14 |
14 |
$205.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$146.00 |
| D1999 |
|
49 |
47 |
$20.00 |