| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
660 |
657 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,151 |
1,135 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
739 |
732 |
$40K |
| D1120 |
Prophylaxis - child |
1,171 |
1,150 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
570 |
567 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
348 |
145 |
$18K |
| D0274 |
Bitewings - four radiographic images |
823 |
814 |
$14K |
| D0330 |
Panoramic radiographic image |
636 |
631 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,526 |
1,261 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,001 |
985 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
99 |
39 |
$6K |
| D9430 |
|
159 |
152 |
$4K |
| D0272 |
Bitewings - two radiographic images |
364 |
357 |
$4K |
| D2394 |
|
36 |
13 |
$2K |
| D1351 |
Sealant - per tooth |
114 |
26 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$1K |
| D0350 |
|
35 |
20 |
$216.00 |