| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,338 |
1,321 |
$78K |
| D0330 |
Panoramic radiographic image |
1,138 |
1,118 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
345 |
188 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
810 |
798 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,406 |
1,382 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
800 |
782 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,051 |
1,040 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
429 |
425 |
$13K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
29 |
25 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
38 |
20 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
27 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
467 |
456 |
$4K |
| D2950 |
|
36 |
26 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$124.64 |