| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,960 |
1,957 |
$103K |
| D0120 |
Periodic oral evaluation - established patient |
1,551 |
1,551 |
$42K |
| D1120 |
Prophylaxis - child |
893 |
892 |
$34K |
| D0330 |
Panoramic radiographic image |
357 |
357 |
$25K |
| D0274 |
Bitewings - four radiographic images |
648 |
648 |
$23K |
| D1206 |
Topical application of fluoride varnish |
731 |
728 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
386 |
383 |
$16K |
| D2740 |
Crown - porcelain/ceramic |
20 |
12 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
369 |
368 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
164 |
164 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
344 |
340 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
30 |
$2K |
| D1354 |
|
50 |
17 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
107 |
99 |
$936.00 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$600.00 |
| D0190 |
|
29 |
27 |
$0.00 |