| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
493 |
487 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
526 |
521 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
419 |
419 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
402 |
396 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,099 |
1,091 |
$18K |
| D4910 |
|
204 |
204 |
$17K |
| D1120 |
Prophylaxis - child |
235 |
235 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
170 |
74 |
$11K |
| D0274 |
Bitewings - four radiographic images |
411 |
411 |
$8K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
13 |
13 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
933 |
534 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
293 |
284 |
$4K |
| D4341 |
|
41 |
12 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
27 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
12 |
$2K |
| D9110 |
|
13 |
13 |
$756.00 |
| D9430 |
|
12 |
12 |
$320.00 |
| D0350 |
|
19 |
14 |
$124.80 |