| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,977 |
2,751 |
$141K |
| D0120 |
Periodic oral evaluation - established patient |
3,170 |
2,931 |
$65K |
| D0274 |
Bitewings - four radiographic images |
1,007 |
930 |
$33K |
| D0140 |
Limited oral evaluation - problem focused |
500 |
456 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
625 |
590 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,161 |
1,059 |
$16K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
24 |
13 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
183 |
135 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
951 |
648 |
$10K |
| D1120 |
Prophylaxis - child |
208 |
188 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
138 |
126 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
44 |
$4K |
| D1351 |
Sealant - per tooth |
58 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
16 |
12 |
$312.00 |