| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,153 |
1,128 |
$60K |
| D2740 |
Crown - porcelain/ceramic |
71 |
38 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,082 |
1,066 |
$24K |
| D0274 |
Bitewings - four radiographic images |
619 |
607 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
412 |
402 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
180 |
176 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
16 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
70 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$806.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$660.00 |