| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,244 |
1,236 |
$107K |
| D0120 |
Periodic oral evaluation - established patient |
734 |
727 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
597 |
596 |
$36K |
| D2740 |
Crown - porcelain/ceramic |
69 |
52 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,742 |
1,640 |
$27K |
| D9430 |
|
821 |
798 |
$26K |
| D4910 |
|
318 |
317 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,444 |
1,437 |
$23K |
| D0350 |
|
2,125 |
641 |
$21K |
| D4341 |
|
293 |
79 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
435 |
434 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,592 |
1,504 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
275 |
122 |
$15K |
| D0274 |
Bitewings - four radiographic images |
477 |
474 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
113 |
75 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
19 |
13 |
$2K |
| D9910 |
|
13 |
13 |
$782.60 |