| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
948 |
914 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
201 |
112 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
600 |
561 |
$13K |
| D2740 |
Crown - porcelain/ceramic |
16 |
13 |
$12K |
| D0274 |
Bitewings - four radiographic images |
236 |
215 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
182 |
177 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
256 |
209 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
26 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
112 |
96 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
14 |
$1K |