| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,186 |
4,185 |
$183K |
| D0120 |
Periodic oral evaluation - established patient |
6,093 |
6,091 |
$135K |
| D0274 |
Bitewings - four radiographic images |
5,595 |
5,594 |
$124K |
| D0210 |
Intraoral - complete series of radiographic images |
2,124 |
2,123 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
553 |
460 |
$30K |
| D1120 |
Prophylaxis - child |
547 |
547 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
467 |
371 |
$17K |
| D2952 |
|
100 |
93 |
$12K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
35 |
29 |
$12K |
| D2791 |
|
29 |
27 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,032 |
1,028 |
$9K |
| D2335 |
|
57 |
54 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
420 |
420 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
285 |
284 |
$3K |
| D2954 |
|
31 |
28 |
$3K |
| D0330 |
Panoramic radiographic image |
91 |
91 |
$2K |
| D3320 |
|
12 |
12 |
$2K |
| D2161 |
|
14 |
12 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$1K |
| D2140 |
|
14 |
13 |
$423.25 |
| D9110 |
|
13 |
13 |
$204.14 |