| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,260 |
1,256 |
$106K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
209 |
135 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
932 |
925 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
668 |
668 |
$46K |
| D0210 |
Intraoral - complete series of radiographic images |
694 |
690 |
$33K |
| D4910 |
|
248 |
246 |
$22K |
| D9430 |
|
557 |
516 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,875 |
989 |
$17K |
| D0274 |
Bitewings - four radiographic images |
632 |
631 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
900 |
791 |
$11K |
| D0330 |
Panoramic radiographic image |
281 |
281 |
$9K |
| D2954 |
|
70 |
47 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
105 |
54 |
$7K |
| D4341 |
|
44 |
12 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
50 |
50 |
$2K |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$323.00 |
| D1999 |
|
67 |
64 |
$146.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$114.00 |
| D1330 |
|
129 |
129 |
$0.00 |