| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,479 |
1,411 |
$53K |
| D2740 |
Crown - porcelain/ceramic |
49 |
38 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,873 |
1,797 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,358 |
1,301 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
333 |
190 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
414 |
217 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
598 |
577 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
731 |
717 |
$13K |
| D1120 |
Prophylaxis - child |
377 |
373 |
$9K |
| D0330 |
Panoramic radiographic image |
156 |
151 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
234 |
230 |
$5K |
| D2394 |
|
54 |
50 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
27 |
$3K |
| D0272 |
Bitewings - two radiographic images |
242 |
237 |
$3K |
| D2335 |
|
33 |
17 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
238 |
228 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
116 |
85 |
$555.00 |