| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
675 |
650 |
$33K |
| D2740 |
Crown - porcelain/ceramic |
29 |
25 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
125 |
62 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
428 |
417 |
$14K |
| D1206 |
Topical application of fluoride varnish |
487 |
473 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
333 |
330 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
422 |
377 |
$7K |
| D0274 |
Bitewings - four radiographic images |
195 |
190 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
180 |
169 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
66 |
65 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
85 |
79 |
$741.09 |