| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,323 |
1,314 |
$111K |
| D0120 |
Periodic oral evaluation - established patient |
1,962 |
1,956 |
$110K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,603 |
1,053 |
$104K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,250 |
1,243 |
$78K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,178 |
3,465 |
$73K |
| D0274 |
Bitewings - four radiographic images |
2,119 |
2,115 |
$44K |
| D1120 |
Prophylaxis - child |
1,168 |
1,165 |
$40K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
463 |
319 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
623 |
616 |
$29K |
| D9430 |
|
591 |
567 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
989 |
986 |
$10K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
15 |
12 |
$7K |
| D0350 |
|
614 |
342 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
90 |
52 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
317 |
304 |
$4K |
| D4910 |
|
39 |
39 |
$3K |