| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,134 |
2,116 |
$95K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
124 |
90 |
$69K |
| D0210 |
Intraoral - complete series of radiographic images |
1,118 |
1,114 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,895 |
1,876 |
$47K |
| D0140 |
Limited oral evaluation - problem focused |
618 |
614 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
975 |
967 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
439 |
217 |
$24K |
| D2954 |
|
110 |
74 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
73 |
50 |
$5K |
| D0274 |
Bitewings - four radiographic images |
328 |
327 |
$4K |
| D0330 |
Panoramic radiographic image |
97 |
93 |
$4K |
| D1120 |
Prophylaxis - child |
51 |
51 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
51 |
51 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
134 |
131 |
$656.00 |
| D1999 |
|
14 |
12 |
$0.00 |