| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,424 |
1,421 |
$124K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
222 |
144 |
$105K |
| D0120 |
Periodic oral evaluation - established patient |
1,165 |
1,160 |
$72K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
771 |
771 |
$48K |
| D0210 |
Intraoral - complete series of radiographic images |
929 |
923 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,713 |
1,704 |
$23K |
| D9430 |
|
717 |
703 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
326 |
235 |
$22K |
| D4910 |
|
217 |
217 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,470 |
735 |
$14K |
| D0274 |
Bitewings - four radiographic images |
455 |
450 |
$10K |
| D4341 |
|
106 |
29 |
$7K |
| D2954 |
|
23 |
15 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
80 |
$996.00 |
| D1206 |
Topical application of fluoride varnish |
47 |
47 |
$819.50 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$764.40 |
| D0350 |
|
35 |
27 |
$374.40 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$360.00 |