| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
444 |
444 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
599 |
599 |
$18K |
| D1206 |
Topical application of fluoride varnish |
275 |
275 |
$9K |
| D1120 |
Prophylaxis - child |
180 |
180 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
114 |
74 |
$8K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
14 |
12 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
292 |
285 |
$4K |
| D0274 |
Bitewings - four radiographic images |
270 |
270 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
26 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
57 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
509 |
497 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
54 |
54 |
$2K |
| D0272 |
Bitewings - two radiographic images |
193 |
193 |
$2K |
| D2954 |
|
15 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
343 |
343 |
$1K |