| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,407 |
1,401 |
$115K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,417 |
1,409 |
$88K |
| D0210 |
Intraoral - complete series of radiographic images |
1,416 |
1,409 |
$66K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
796 |
443 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
677 |
673 |
$38K |
| D1206 |
Topical application of fluoride varnish |
2,193 |
2,186 |
$32K |
| D0350 |
|
3,220 |
1,429 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
385 |
244 |
$25K |
| D1120 |
Prophylaxis - child |
373 |
370 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,944 |
756 |
$8K |
| D4910 |
|
95 |
95 |
$7K |
| D0274 |
Bitewings - four radiographic images |
347 |
344 |
$7K |
| D9430 |
|
119 |
115 |
$3K |
| D2140 |
|
66 |
31 |
$3K |
| D4341 |
|
38 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
156 |
151 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
20 |
15 |
$1K |