| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,569 |
4,117 |
$213K |
| D2740 |
Crown - porcelain/ceramic |
259 |
121 |
$183K |
| D0120 |
Periodic oral evaluation - established patient |
4,225 |
3,805 |
$83K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
41 |
26 |
$23K |
| D2954 |
|
116 |
94 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
259 |
251 |
$18K |
| D0274 |
Bitewings - four radiographic images |
323 |
320 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
841 |
702 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
238 |
223 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
120 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
115 |
113 |
$5K |
| D0272 |
Bitewings - two radiographic images |
74 |
71 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
18 |
13 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$1K |
| D9110 |
|
32 |
25 |
$909.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
50 |
39 |
$620.00 |
| D1330 |
|
12 |
12 |
$168.00 |