| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,777 |
1,761 |
$155K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
316 |
251 |
$149K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,471 |
1,467 |
$96K |
| D0210 |
Intraoral - complete series of radiographic images |
1,595 |
1,590 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
751 |
745 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
573 |
404 |
$38K |
| D1206 |
Topical application of fluoride varnish |
2,187 |
2,170 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
662 |
405 |
$36K |
| D9430 |
|
949 |
931 |
$30K |
| D0350 |
|
2,340 |
1,181 |
$22K |
| D0274 |
Bitewings - four radiographic images |
695 |
691 |
$15K |
| D1320 |
|
729 |
729 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,642 |
1,427 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
497 |
486 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
98 |
28 |
$5K |
| D4910 |
|
69 |
69 |
$5K |
| D1120 |
Prophylaxis - child |
132 |
131 |
$5K |
| D2330 |
|
45 |
31 |
$3K |
| D4341 |
|
44 |
12 |
$3K |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$192.00 |