| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
423 |
414 |
$23K |
| D2740 |
Crown - porcelain/ceramic |
30 |
14 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
465 |
416 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
293 |
290 |
$7K |
| D0274 |
Bitewings - four radiographic images |
185 |
180 |
$6K |
| D2950 |
|
46 |
28 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
112 |
98 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
301 |
222 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
27 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
24 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$1K |