| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,270 |
5,054 |
$265K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
261 |
161 |
$151K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,717 |
1,107 |
$149K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,838 |
1,257 |
$147K |
| D0120 |
Periodic oral evaluation - established patient |
5,447 |
5,246 |
$127K |
| D1120 |
Prophylaxis - child |
1,663 |
1,614 |
$81K |
| D0274 |
Bitewings - four radiographic images |
2,208 |
2,140 |
$79K |
| D0210 |
Intraoral - complete series of radiographic images |
1,008 |
936 |
$66K |
| D8670 |
Periodic orthodontic treatment visit |
272 |
239 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,352 |
1,297 |
$58K |
| D1206 |
Topical application of fluoride varnish |
2,068 |
2,013 |
$52K |
| D0140 |
Limited oral evaluation - problem focused |
1,253 |
1,187 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
629 |
446 |
$39K |
| D0220 |
Intraoral - periapical first radiographic image |
1,634 |
1,519 |
$24K |
| D3120 |
|
366 |
178 |
$12K |
| D2394 |
|
66 |
49 |
$7K |
| D2335 |
|
24 |
12 |
$3K |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$2K |
| D1351 |
Sealant - per tooth |
42 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$1K |