| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,204 |
1,196 |
$47K |
| D2740 |
Crown - porcelain/ceramic |
54 |
26 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,262 |
1,535 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,065 |
1,062 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,254 |
1,247 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
210 |
91 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,856 |
1,803 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
493 |
490 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
149 |
58 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
320 |
319 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
454 |
454 |
$8K |
| D9945 |
|
27 |
27 |
$6K |
| D0330 |
Panoramic radiographic image |
39 |
39 |
$3K |
| D1120 |
Prophylaxis - child |
116 |
116 |
$3K |
| D2950 |
|
19 |
14 |
$2K |
| D0350 |
|
73 |
73 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
30 |
12 |
$2K |
| D1320 |
|
12 |
12 |
$180.00 |