| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
723 |
721 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
894 |
891 |
$59K |
| D0210 |
Intraoral - complete series of radiographic images |
680 |
677 |
$32K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
57 |
30 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
291 |
291 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
321 |
172 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,379 |
1,375 |
$19K |
| D9430 |
|
285 |
260 |
$9K |
| D0330 |
Panoramic radiographic image |
250 |
250 |
$7K |
| D0274 |
Bitewings - four radiographic images |
375 |
375 |
$7K |
| D0350 |
|
681 |
226 |
$6K |
| D1120 |
Prophylaxis - child |
134 |
134 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
97 |
54 |
$5K |
| D2954 |
|
51 |
28 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,210 |
573 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
24 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
214 |
208 |
$3K |