| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,136 |
1,128 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,442 |
1,439 |
$43K |
| D2740 |
Crown - porcelain/ceramic |
21 |
14 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,322 |
1,298 |
$7K |
| D0274 |
Bitewings - four radiographic images |
538 |
536 |
$6K |
| D1120 |
Prophylaxis - child |
109 |
105 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
128 |
128 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
254 |
249 |
$3K |
| D1206 |
Topical application of fluoride varnish |
81 |
79 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
610 |
608 |
$2K |
| D2954 |
|
17 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$495.00 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
13 |
$450.00 |