| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,467 |
1,456 |
$123K |
| D0120 |
Periodic oral evaluation - established patient |
2,076 |
2,060 |
$111K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,769 |
2,750 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,573 |
1,559 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,037 |
2,157 |
$33K |
| D1120 |
Prophylaxis - child |
798 |
791 |
$27K |
| D9430 |
|
822 |
772 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
285 |
285 |
$16K |
| D2740 |
Crown - porcelain/ceramic |
34 |
28 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
118 |
66 |
$8K |
| D0350 |
|
447 |
279 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
298 |
286 |
$4K |
| D4341 |
|
36 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
98 |
26 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
16 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$1K |
| D1330 |
|
40 |
40 |
$0.00 |
| D1310 |
|
45 |
45 |
$0.00 |