| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,850 |
1,848 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
2,393 |
2,387 |
$45K |
| D0330 |
Panoramic radiographic image |
1,017 |
1,017 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,658 |
1,631 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
533 |
533 |
$12K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
27 |
15 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
845 |
835 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
970 |
933 |
$7K |
| D0274 |
Bitewings - four radiographic images |
174 |
172 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
42 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
15 |
$1K |
| D5422 |
|
12 |
12 |
$226.00 |