| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,022 |
2,001 |
$109K |
| D0274 |
Bitewings - four radiographic images |
1,646 |
1,634 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
749 |
729 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,282 |
1,271 |
$31K |
| D2740 |
Crown - porcelain/ceramic |
41 |
28 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
537 |
530 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
651 |
622 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
146 |
81 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
297 |
294 |
$9K |
| D1120 |
Prophylaxis - child |
157 |
156 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
75 |
74 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
15 |
$225.00 |