| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,298 |
1,265 |
$66K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
115 |
21 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,387 |
1,351 |
$32K |
| D1120 |
Prophylaxis - child |
544 |
532 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
734 |
708 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
281 |
276 |
$19K |
| D0274 |
Bitewings - four radiographic images |
452 |
443 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
376 |
367 |
$16K |
| D2954 |
|
28 |
12 |
$5K |
| D0330 |
Panoramic radiographic image |
26 |
24 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
49 |
49 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
45 |
42 |
$618.00 |
| D1999 |
|
130 |
124 |
$0.00 |