| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,479 |
1,468 |
$131K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,834 |
1,829 |
$121K |
| D0350 |
|
11,009 |
3,534 |
$103K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,427 |
831 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
1,110 |
1,095 |
$95K |
| D4341 |
|
1,289 |
347 |
$90K |
| D4910 |
|
1,154 |
1,146 |
$89K |
| D0210 |
Intraoral - complete series of radiographic images |
1,556 |
1,555 |
$74K |
| D1120 |
Prophylaxis - child |
1,026 |
1,020 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,508 |
2,491 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,291 |
1,590 |
$33K |
| D1320 |
|
2,411 |
2,390 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
370 |
278 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
481 |
289 |
$26K |
| D0274 |
Bitewings - four radiographic images |
958 |
946 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
211 |
211 |
$3K |
| D1351 |
Sealant - per tooth |
128 |
31 |
$2K |
| D4342 |
|
33 |
13 |
$1K |
| D9430 |
|
25 |
25 |
$800.00 |