| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
831 |
829 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
1,144 |
1,141 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,111 |
1,105 |
$70K |
| D4910 |
|
687 |
687 |
$53K |
| D0210 |
Intraoral - complete series of radiographic images |
1,102 |
1,098 |
$51K |
| D9430 |
|
924 |
815 |
$30K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
63 |
61 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,701 |
1,679 |
$27K |
| D0350 |
|
2,604 |
753 |
$24K |
| D2740 |
Crown - porcelain/ceramic |
43 |
26 |
$20K |
| D1120 |
Prophylaxis - child |
364 |
364 |
$13K |
| D1206 |
Topical application of fluoride varnish |
757 |
755 |
$13K |
| D4341 |
|
183 |
49 |
$12K |
| D0272 |
Bitewings - two radiographic images |
991 |
986 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
42 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
440 |
440 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
25 |
$2K |
| D0270 |
|
266 |
257 |
$1K |