| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,343 |
1,330 |
$120K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,329 |
1,315 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
795 |
786 |
$62K |
| D0210 |
Intraoral - complete series of radiographic images |
828 |
825 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,824 |
1,264 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
597 |
261 |
$32K |
| D4341 |
|
405 |
139 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,505 |
1,490 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
291 |
199 |
$19K |
| D1120 |
Prophylaxis - child |
272 |
272 |
$14K |
| D0272 |
Bitewings - two radiographic images |
808 |
800 |
$10K |
| D4910 |
|
120 |
120 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
154 |
74 |
$9K |
| D4342 |
|
138 |
51 |
$6K |
| D2330 |
|
58 |
27 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
20 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
64 |
64 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
31 |
31 |
$449.50 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$156.00 |