| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
3,283 |
2,416 |
$103K |
| D0350 |
|
11,212 |
2,180 |
$100K |
| D1110 |
Prophylaxis - adult |
668 |
667 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,469 |
1,460 |
$52K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
439 |
170 |
$35K |
| D4910 |
|
438 |
435 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
445 |
445 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
536 |
535 |
$25K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
50 |
28 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,914 |
1,905 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
912 |
797 |
$11K |
| D2332 |
|
105 |
26 |
$10K |
| D9910 |
|
202 |
201 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,112 |
1,100 |
$8K |
| D2335 |
|
29 |
12 |
$3K |
| D2394 |
|
40 |
24 |
$3K |
| D0274 |
Bitewings - four radiographic images |
136 |
135 |
$3K |
| D2954 |
|
20 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
54 |
54 |
$2K |
| D0270 |
|
12 |
12 |
$60.00 |