| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,466 |
2,415 |
$125K |
| D0120 |
Periodic oral evaluation - established patient |
1,657 |
1,627 |
$35K |
| D2740 |
Crown - porcelain/ceramic |
49 |
37 |
$35K |
| D0274 |
Bitewings - four radiographic images |
552 |
538 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
206 |
136 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
903 |
878 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
642 |
624 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
65 |
65 |
$3K |