| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,031 |
3,022 |
$254K |
| D0120 |
Periodic oral evaluation - established patient |
3,399 |
3,389 |
$205K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,362 |
1,191 |
$158K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,405 |
2,403 |
$153K |
| D2740 |
Crown - porcelain/ceramic |
278 |
198 |
$129K |
| D0230 |
Intraoral - periapical each additional radiographic image |
26,468 |
4,920 |
$107K |
| D1120 |
Prophylaxis - child |
2,690 |
2,683 |
$104K |
| D0210 |
Intraoral - complete series of radiographic images |
1,626 |
1,625 |
$76K |
| D0274 |
Bitewings - four radiographic images |
3,643 |
3,633 |
$76K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,880 |
4,870 |
$62K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,087 |
588 |
$59K |
| D9430 |
|
1,189 |
1,126 |
$38K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
545 |
303 |
$36K |
| D2332 |
|
377 |
149 |
$30K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
376 |
241 |
$30K |
| D0350 |
|
2,762 |
687 |
$26K |
| D1206 |
Topical application of fluoride varnish |
652 |
652 |
$6K |
| D2954 |
|
36 |
26 |
$4K |
| D2140 |
|
69 |
39 |
$4K |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$240.00 |