| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,826 |
1,809 |
$87K |
| D2740 |
Crown - porcelain/ceramic |
63 |
52 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,382 |
1,375 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,168 |
1,157 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
463 |
457 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,273 |
1,253 |
$16K |
| D0330 |
Panoramic radiographic image |
303 |
301 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
610 |
600 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
27 |
$7K |
| D2950 |
|
44 |
38 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
12 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
94 |
93 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
96 |
96 |
$2K |
| D0383 |
|
13 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$194.88 |