| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,437 |
1,437 |
$37K |
| D1120 |
Prophylaxis - child |
719 |
719 |
$22K |
| D1110 |
Prophylaxis - adult |
657 |
657 |
$21K |
| D2740 |
Crown - porcelain/ceramic |
44 |
37 |
$18K |
| D1206 |
Topical application of fluoride varnish |
772 |
772 |
$15K |
| D0330 |
Panoramic radiographic image |
424 |
424 |
$13K |
| D0251 |
|
623 |
623 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
61 |
40 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
451 |
451 |
$4K |
| D0274 |
Bitewings - four radiographic images |
219 |
219 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
34 |
$3K |
| D0601 |
|
155 |
155 |
$2K |
| D2950 |
|
26 |
24 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$925.00 |
| D0140 |
Limited oral evaluation - problem focused |
135 |
133 |
$613.00 |
| D0220 |
Intraoral - periapical first radiographic image |
49 |
48 |
$272.00 |
| D9995 |
|
109 |
108 |
$0.00 |