| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,047 |
2,037 |
$82K |
| D0120 |
Periodic oral evaluation - established patient |
2,130 |
2,119 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
585 |
580 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
252 |
124 |
$22K |
| D2740 |
Crown - porcelain/ceramic |
24 |
16 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
604 |
600 |
$17K |
| D0274 |
Bitewings - four radiographic images |
451 |
448 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
162 |
69 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
391 |
390 |
$9K |
| D1120 |
Prophylaxis - child |
224 |
224 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
305 |
296 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
503 |
490 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
57 |
45 |
$240.77 |