| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,698 |
2,698 |
$98K |
| D0120 |
Periodic oral evaluation - established patient |
2,467 |
2,467 |
$49K |
| D0274 |
Bitewings - four radiographic images |
2,238 |
2,238 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
2,483 |
2,481 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
342 |
223 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
533 |
531 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,266 |
2,266 |
$11K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
14 |
12 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
64 |
49 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
141 |
141 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
40 |
$2K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$345.08 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$147.60 |