| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,496 |
1,495 |
$60K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
361 |
329 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
563 |
563 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
960 |
960 |
$19K |
| D0274 |
Bitewings - four radiographic images |
933 |
933 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
779 |
779 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,224 |
1,219 |
$12K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
29 |
26 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,082 |
1,080 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
89 |
84 |
$6K |
| D1120 |
Prophylaxis - child |
103 |
103 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
255 |
255 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
151 |
151 |
$1K |
| D2954 |
|
14 |
13 |
$1K |
| D9430 |
|
53 |
52 |
$685.82 |
| D9110 |
|
15 |
15 |
$267.90 |