| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,177 |
3,177 |
$124K |
| D0120 |
Periodic oral evaluation - established patient |
3,816 |
3,814 |
$76K |
| D0274 |
Bitewings - four radiographic images |
2,187 |
2,187 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
4,503 |
4,452 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,014 |
3,993 |
$35K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
48 |
38 |
$17K |
| D2954 |
|
52 |
38 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
44 |
$482.20 |
| D0140 |
Limited oral evaluation - problem focused |
50 |
49 |
$468.74 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$376.89 |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
25 |
$227.30 |
| D1999 |
|
42 |
42 |
$0.00 |