| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,734 |
1,734 |
$72K |
| D9944 |
|
501 |
501 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
807 |
359 |
$48K |
| D9990 |
|
2,005 |
1,807 |
$46K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
83 |
62 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,778 |
1,775 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,199 |
1,199 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
1,176 |
1,173 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
858 |
858 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,937 |
1,929 |
$17K |
| D0274 |
Bitewings - four radiographic images |
729 |
729 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
357 |
166 |
$15K |
| D1120 |
Prophylaxis - child |
196 |
196 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
395 |
395 |
$5K |
| D2954 |
|
54 |
41 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
298 |
284 |
$3K |
| D0272 |
Bitewings - two radiographic images |
165 |
165 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$323.86 |