| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,758 |
1,749 |
$89K |
| D2740 |
Crown - porcelain/ceramic |
103 |
66 |
$78K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
962 |
959 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,524 |
1,517 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
287 |
188 |
$39K |
| D0274 |
Bitewings - four radiographic images |
889 |
888 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,651 |
1,628 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,143 |
1,140 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
375 |
370 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
183 |
182 |
$14K |
| D2950 |
|
83 |
62 |
$11K |
| D1206 |
Topical application of fluoride varnish |
283 |
283 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
24 |
$3K |
| D1120 |
Prophylaxis - child |
41 |
41 |
$2K |