| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
681 |
677 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
751 |
751 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
665 |
357 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
590 |
283 |
$32K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
50 |
30 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
386 |
385 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,438 |
1,433 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
336 |
336 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,769 |
1,042 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
152 |
87 |
$12K |
| D0274 |
Bitewings - four radiographic images |
595 |
594 |
$11K |
| D0350 |
|
594 |
388 |
$10K |
| D1120 |
Prophylaxis - child |
308 |
308 |
$9K |
| D2954 |
|
82 |
49 |
$8K |
| D4341 |
|
98 |
27 |
$7K |
| D9430 |
|
127 |
108 |
$4K |
| D2330 |
|
35 |
17 |
$3K |
| D4910 |
|
29 |
29 |
$2K |
| D1351 |
Sealant - per tooth |
77 |
19 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
16 |
$192.00 |