| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,532 |
3,523 |
$229K |
| D2740 |
Crown - porcelain/ceramic |
250 |
231 |
$215K |
| D0120 |
Periodic oral evaluation - established patient |
3,500 |
3,493 |
$115K |
| D0274 |
Bitewings - four radiographic images |
1,757 |
1,756 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
315 |
286 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
586 |
586 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
941 |
921 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
321 |
315 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
38 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
371 |
367 |
$6K |
| D0330 |
Panoramic radiographic image |
161 |
161 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
175 |
175 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
25 |
$2K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$1K |
| D0350 |
|
26 |
26 |
$112.70 |
| D1999 |
|
244 |
235 |
$0.00 |