| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,384 |
1,379 |
$120K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,627 |
1,617 |
$102K |
| D0120 |
Periodic oral evaluation - established patient |
1,528 |
1,520 |
$95K |
| D0210 |
Intraoral - complete series of radiographic images |
1,563 |
1,554 |
$73K |
| D0350 |
|
7,886 |
1,898 |
$63K |
| D1120 |
Prophylaxis - child |
1,416 |
1,412 |
$57K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
813 |
340 |
$44K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,101 |
1,745 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,026 |
2,012 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
393 |
234 |
$26K |
| D9430 |
|
492 |
456 |
$16K |
| D1206 |
Topical application of fluoride varnish |
960 |
959 |
$13K |
| D0274 |
Bitewings - four radiographic images |
621 |
618 |
$13K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
176 |
99 |
$12K |
| D1320 |
|
603 |
601 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
53 |
37 |
$6K |
| D4910 |
|
74 |
74 |
$6K |
| D0272 |
Bitewings - two radiographic images |
135 |
135 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
13 |
$1K |
| D9993 |
|
12 |
12 |
$780.00 |
| D1310 |
|
12 |
12 |
$552.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$390.00 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$300.00 |