| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,240 |
1,022 |
$52K |
| D2740 |
Crown - porcelain/ceramic |
67 |
37 |
$40K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
53 |
29 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
309 |
270 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
687 |
565 |
$9K |
| D0274 |
Bitewings - four radiographic images |
247 |
220 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
29 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
326 |
160 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
68 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
27 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
29 |
27 |
$612.00 |