| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,010 |
3,007 |
$130K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
970 |
715 |
$83K |
| D0274 |
Bitewings - four radiographic images |
1,967 |
1,967 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,873 |
1,873 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
3,299 |
3,271 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,034 |
1,034 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,098 |
2,098 |
$22K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
40 |
40 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
436 |
433 |
$14K |
| D0330 |
Panoramic radiographic image |
428 |
428 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
945 |
937 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
94 |
81 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
74 |
65 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
364 |
364 |
$4K |
| D2954 |
|
29 |
28 |
$4K |
| D4341 |
|
14 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
27 |
26 |
$739.68 |