| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,660 |
1,595 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
1,880 |
1,843 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,170 |
1,133 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
415 |
249 |
$30K |
| D2954 |
|
131 |
98 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,574 |
1,517 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
762 |
737 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,467 |
1,055 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
292 |
276 |
$12K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
21 |
12 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
177 |
172 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
78 |
53 |
$7K |
| D1120 |
Prophylaxis - child |
83 |
83 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$875.04 |
| D1206 |
Topical application of fluoride varnish |
28 |
28 |
$795.76 |