| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,074 |
2,061 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,464 |
1,451 |
$26K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
86 |
69 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,244 |
1,230 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
377 |
251 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
514 |
510 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
2,028 |
1,952 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
186 |
91 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,061 |
959 |
$5K |
| D2954 |
|
103 |
86 |
$5K |
| D0274 |
Bitewings - four radiographic images |
362 |
354 |
$3K |
| D1120 |
Prophylaxis - child |
93 |
93 |
$3K |
| D2740 |
Crown - porcelain/ceramic |
13 |
12 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$245.00 |