| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,112 |
2,107 |
$188K |
| D4910 |
|
1,747 |
1,739 |
$134K |
| D0120 |
Periodic oral evaluation - established patient |
1,607 |
1,600 |
$117K |
| D2740 |
Crown - porcelain/ceramic |
212 |
154 |
$101K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,434 |
1,428 |
$93K |
| D0210 |
Intraoral - complete series of radiographic images |
1,289 |
1,284 |
$61K |
| D4341 |
|
754 |
200 |
$53K |
| D1206 |
Topical application of fluoride varnish |
1,729 |
1,723 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
294 |
215 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
223 |
180 |
$18K |
| D1120 |
Prophylaxis - child |
324 |
324 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
652 |
652 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
67 |
40 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
410 |
396 |
$5K |
| D3221 |
|
76 |
67 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
901 |
280 |
$4K |
| D0350 |
|
186 |
139 |
$2K |
| D2954 |
|
13 |
12 |
$1K |
| D2394 |
|
13 |
12 |
$1K |
| D9430 |
|
14 |
14 |
$448.00 |
| D0270 |
|
66 |
63 |
$330.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$237.60 |