| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,892 |
1,849 |
$97K |
| D2740 |
Crown - porcelain/ceramic |
106 |
63 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
527 |
270 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,139 |
1,125 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
531 |
508 |
$22K |
| D0274 |
Bitewings - four radiographic images |
667 |
656 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,197 |
1,074 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
220 |
207 |
$15K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
179 |
171 |
$6K |
| D1206 |
Topical application of fluoride varnish |
211 |
206 |
$6K |
| D0330 |
Panoramic radiographic image |
61 |
60 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
244 |
203 |
$3K |
| D2950 |
|
14 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
32 |
30 |
$2K |