| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,060 |
3,060 |
$129K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,074 |
789 |
$117K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
272 |
160 |
$105K |
| D0120 |
Periodic oral evaluation - established patient |
3,086 |
3,086 |
$66K |
| D0274 |
Bitewings - four radiographic images |
2,313 |
2,313 |
$50K |
| D0220 |
Intraoral - periapical first radiographic image |
2,957 |
2,937 |
$31K |
| D0330 |
Panoramic radiographic image |
841 |
841 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
388 |
311 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,491 |
1,491 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
186 |
145 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
657 |
657 |
$15K |
| D1120 |
Prophylaxis - child |
460 |
460 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,615 |
2,614 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
308 |
307 |
$11K |
| D2394 |
|
57 |
53 |
$9K |
| D0272 |
Bitewings - two radiographic images |
531 |
531 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
39 |
$387.64 |
| D0350 |
|
16 |
16 |
$182.69 |