| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,536 |
1,528 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
1,728 |
1,718 |
$36K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
99 |
42 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
1,430 |
1,420 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,900 |
1,888 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,996 |
1,979 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
116 |
76 |
$9K |
| D2954 |
|
30 |
17 |
$3K |
| D0274 |
Bitewings - four radiographic images |
139 |
139 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
107 |
106 |
$2K |
| D1330 |
|
109 |
109 |
$1K |
| D1310 |
|
110 |
110 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$780.00 |
| D9110 |
|
12 |
12 |
$360.00 |
| D1320 |
|
16 |
16 |
$120.01 |