| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
1,550 |
1,464 |
$67K |
| D2740 |
Crown - porcelain/ceramic |
123 |
97 |
$66K |
| D1110 |
Prophylaxis - adult |
1,341 |
1,339 |
$59K |
| D4355 |
|
455 |
451 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,932 |
1,930 |
$48K |
| D0210 |
Intraoral - complete series of radiographic images |
545 |
544 |
$24K |
| D0274 |
Bitewings - four radiographic images |
1,720 |
1,718 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
281 |
121 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,144 |
2,121 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
2,548 |
2,472 |
$13K |
| D4910 |
|
65 |
65 |
$6K |
| D5422 |
|
293 |
238 |
$4K |
| D5421 |
|
236 |
194 |
$4K |
| D4341 |
|
34 |
14 |
$2K |
| D1206 |
Topical application of fluoride varnish |
67 |
67 |
$2K |
| D2330 |
|
36 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
15 |
15 |
$675.00 |
| D0272 |
Bitewings - two radiographic images |
57 |
57 |
$570.00 |