| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,227 |
4,171 |
$226K |
| D2740 |
Crown - porcelain/ceramic |
215 |
126 |
$155K |
| D0120 |
Periodic oral evaluation - established patient |
4,205 |
4,159 |
$101K |
| D0220 |
Intraoral - periapical first radiographic image |
4,092 |
3,999 |
$65K |
| D0274 |
Bitewings - four radiographic images |
1,713 |
1,687 |
$61K |
| D1120 |
Prophylaxis - child |
851 |
846 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,939 |
2,638 |
$40K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
58 |
36 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,054 |
1,047 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
609 |
602 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
275 |
223 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
290 |
169 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
214 |
212 |
$9K |
| D0272 |
Bitewings - two radiographic images |
55 |
55 |
$2K |