| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,649 |
1,648 |
$147K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,662 |
1,660 |
$109K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,238 |
521 |
$67K |
| D0210 |
Intraoral - complete series of radiographic images |
1,310 |
1,309 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
758 |
758 |
$60K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
764 |
429 |
$50K |
| D1120 |
Prophylaxis - child |
598 |
595 |
$30K |
| D9430 |
|
941 |
904 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,617 |
1,616 |
$28K |
| D4910 |
|
178 |
178 |
$14K |
| D0274 |
Bitewings - four radiographic images |
614 |
614 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
518 |
517 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,723 |
936 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
403 |
395 |
$5K |
| D4341 |
|
52 |
14 |
$4K |
| D1351 |
Sealant - per tooth |
53 |
12 |
$2K |
| D0270 |
|
12 |
12 |
$60.00 |