| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,253 |
1,175 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
1,258 |
1,191 |
$27K |
| D2740 |
Crown - porcelain/ceramic |
23 |
16 |
$14K |
| D0274 |
Bitewings - four radiographic images |
390 |
367 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
112 |
69 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
180 |
154 |
$6K |
| D1120 |
Prophylaxis - child |
128 |
120 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
167 |
157 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
29 |
$3K |
| D2950 |
|
16 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
176 |
151 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
26 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
14 |
$1K |