| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,591 |
1,566 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
1,908 |
1,861 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
249 |
148 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
571 |
560 |
$24K |
| D2740 |
Crown - porcelain/ceramic |
29 |
24 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
239 |
235 |
$19K |
| D4910 |
|
126 |
117 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
570 |
548 |
$8K |
| D1206 |
Topical application of fluoride varnish |
314 |
299 |
$7K |
| D0274 |
Bitewings - four radiographic images |
174 |
173 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
107 |
104 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
124 |
120 |
$3K |
| D2950 |
|
17 |
13 |
$2K |