| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,363 |
3,362 |
$120K |
| D0120 |
Periodic oral evaluation - established patient |
3,424 |
3,424 |
$68K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
176 |
139 |
$59K |
| D0274 |
Bitewings - four radiographic images |
2,857 |
2,857 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
264 |
264 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
140 |
140 |
$4K |
| D0330 |
Panoramic radiographic image |
156 |
156 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
37 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
141 |
141 |
$2K |
| D2954 |
|
13 |
13 |
$1K |
| D1120 |
Prophylaxis - child |
32 |
32 |
$981.97 |
| D0220 |
Intraoral - periapical first radiographic image |
59 |
59 |
$510.98 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$61.59 |
| D1999 |
|
39 |
36 |
$0.00 |