| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,636 |
1,635 |
$60K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
114 |
80 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
1,282 |
1,278 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,318 |
1,317 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,015 |
1,015 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
619 |
615 |
$11K |
| D2954 |
|
94 |
76 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
708 |
706 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
406 |
406 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
106 |
62 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
50 |
$4K |
| D1120 |
Prophylaxis - child |
51 |
51 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
125 |
125 |
$1K |