| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,142 |
1,141 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
1,903 |
1,903 |
$75K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
808 |
807 |
$48K |
| D1120 |
Prophylaxis - child |
1,368 |
1,368 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
856 |
856 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,491 |
1,490 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
428 |
238 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,600 |
2,599 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,611 |
1,846 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
123 |
81 |
$7K |
| D9430 |
|
210 |
205 |
$7K |
| D1351 |
Sealant - per tooth |
247 |
40 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
286 |
280 |
$3K |
| D4341 |
|
37 |
12 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
15 |
12 |
$2K |
| D4910 |
|
16 |
16 |
$1K |