| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,580 |
2,553 |
$230K |
| D0120 |
Periodic oral evaluation - established patient |
2,476 |
2,448 |
$204K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,302 |
2,289 |
$152K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
317 |
262 |
$150K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,116 |
1,312 |
$142K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,612 |
1,000 |
$87K |
| D0210 |
Intraoral - complete series of radiographic images |
1,815 |
1,802 |
$86K |
| D1120 |
Prophylaxis - child |
1,780 |
1,759 |
$84K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,936 |
4,182 |
$78K |
| D1206 |
Topical application of fluoride varnish |
3,404 |
3,358 |
$57K |
| D0274 |
Bitewings - four radiographic images |
2,638 |
2,608 |
$56K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
656 |
492 |
$52K |
| D9430 |
|
1,532 |
1,477 |
$49K |
| D4910 |
|
486 |
485 |
$37K |
| D2330 |
|
275 |
167 |
$21K |
| D4341 |
|
175 |
47 |
$12K |
| D1320 |
|
766 |
761 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
880 |
878 |
$11K |
| D0270 |
|
1,084 |
1,056 |
$5K |
| D0350 |
|
632 |
285 |
$5K |
| D2331 |
|
15 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$132.00 |
| D1330 |
|
94 |
93 |
$0.00 |