| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
352 |
345 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
390 |
386 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
263 |
260 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,723 |
1,042 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
210 |
210 |
$11K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
16 |
13 |
$8K |
| D9430 |
|
207 |
206 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
269 |
267 |
$3K |
| D0274 |
Bitewings - four radiographic images |
54 |
52 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
13 |
$1K |
| D4910 |
|
12 |
12 |
$924.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$360.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$126.00 |