| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,734 |
1,728 |
$149K |
| D0120 |
Periodic oral evaluation - established patient |
1,817 |
1,812 |
$111K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,580 |
1,579 |
$101K |
| D4910 |
|
1,011 |
1,004 |
$77K |
| D0210 |
Intraoral - complete series of radiographic images |
1,230 |
1,229 |
$58K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
96 |
69 |
$46K |
| D0250 |
|
1,993 |
1,864 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
3,587 |
3,234 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,963 |
2,955 |
$38K |
| D1120 |
Prophylaxis - child |
980 |
979 |
$37K |
| D4341 |
|
428 |
159 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,228 |
1,228 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,052 |
2,446 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
352 |
263 |
$19K |
| D0350 |
|
2,426 |
964 |
$14K |
| D9110 |
|
220 |
214 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
122 |
93 |
$8K |
| D9430 |
|
118 |
114 |
$4K |
| D2954 |
|
36 |
25 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
39 |
$4K |
| D2394 |
|
16 |
13 |
$1K |
| D2330 |
|
16 |
12 |
$1K |
| D1351 |
Sealant - per tooth |
51 |
13 |
$1K |
| D3221 |
|
13 |
12 |
$819.00 |
| D1999 |
|
43 |
36 |
$46.00 |
| D0260 |
|
18 |
12 |
$0.00 |