| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,079 |
1,070 |
$94K |
| D2740 |
Crown - porcelain/ceramic |
187 |
142 |
$89K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,060 |
1,052 |
$70K |
| D9430 |
|
1,816 |
1,570 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
462 |
462 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
476 |
225 |
$32K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
357 |
168 |
$28K |
| D4341 |
|
350 |
96 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,357 |
1,348 |
$23K |
| D0274 |
Bitewings - four radiographic images |
834 |
828 |
$18K |
| D4910 |
|
219 |
219 |
$16K |
| D0350 |
|
1,748 |
828 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
306 |
301 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,415 |
1,312 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
693 |
637 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
55 |
24 |
$6K |
| D3221 |
|
78 |
55 |
$5K |
| D2335 |
|
27 |
14 |
$3K |
| D2332 |
|
40 |
13 |
$3K |
| D1120 |
Prophylaxis - child |
57 |
57 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
14 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
111 |
111 |
$1K |