| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,100 |
1,095 |
$91K |
| D2740 |
Crown - porcelain/ceramic |
182 |
116 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
1,113 |
1,102 |
$73K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,147 |
1,138 |
$70K |
| D4910 |
|
740 |
737 |
$56K |
| D0210 |
Intraoral - complete series of radiographic images |
941 |
932 |
$43K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
80 |
55 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
577 |
321 |
$38K |
| D1120 |
Prophylaxis - child |
744 |
733 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,208 |
1,291 |
$25K |
| D4341 |
|
320 |
88 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,434 |
1,421 |
$18K |
| D0350 |
|
1,648 |
874 |
$16K |
| D2954 |
|
152 |
108 |
$16K |
| D0274 |
Bitewings - four radiographic images |
713 |
707 |
$15K |
| D1206 |
Topical application of fluoride varnish |
691 |
691 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
147 |
67 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
310 |
299 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D9430 |
|
15 |
14 |
$480.00 |