| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,982 |
1,969 |
$167K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,640 |
803 |
$107K |
| D0120 |
Periodic oral evaluation - established patient |
1,827 |
1,819 |
$103K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,290 |
1,289 |
$81K |
| D0210 |
Intraoral - complete series of radiographic images |
803 |
801 |
$37K |
| D0350 |
|
3,580 |
1,260 |
$32K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
57 |
38 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,809 |
1,798 |
$23K |
| D1120 |
Prophylaxis - child |
600 |
598 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
412 |
221 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,000 |
993 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,276 |
1,882 |
$17K |
| D9430 |
|
149 |
148 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
368 |
357 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
57 |
41 |
$4K |
| D4910 |
|
41 |
41 |
$3K |
| D4341 |
|
37 |
14 |
$3K |