| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,075 |
2,010 |
$106K |
| D2740 |
Crown - porcelain/ceramic |
90 |
49 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
1,864 |
1,816 |
$42K |
| D0274 |
Bitewings - four radiographic images |
675 |
659 |
$23K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
38 |
26 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
130 |
92 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
216 |
209 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
106 |
105 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
394 |
367 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
37 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
81 |
79 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
54 |
$2K |
| D1120 |
Prophylaxis - child |
38 |
38 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
138 |
88 |
$1K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$862.00 |
| D0180 |
|
12 |
12 |
$444.00 |
| D1330 |
|
12 |
12 |
$0.00 |