| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,287 |
1,184 |
$62K |
| D9110 |
|
1,439 |
1,130 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
945 |
857 |
$19K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
12 |
12 |
$7K |
| D0274 |
Bitewings - four radiographic images |
203 |
194 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
28 |
$2K |
| D0330 |
Panoramic radiographic image |
31 |
29 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
39 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$847.00 |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
39 |
$533.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$348.00 |
| D1999 |
|
65 |
61 |
$0.00 |