| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,682 |
1,670 |
$139K |
| D0120 |
Periodic oral evaluation - established patient |
1,937 |
1,919 |
$106K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,601 |
1,583 |
$96K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
938 |
394 |
$62K |
| D0350 |
|
7,381 |
1,998 |
$55K |
| D0210 |
Intraoral - complete series of radiographic images |
979 |
970 |
$46K |
| D9430 |
|
1,450 |
1,428 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
850 |
296 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,682 |
2,912 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,862 |
2,846 |
$36K |
| D1120 |
Prophylaxis - child |
1,041 |
1,035 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,767 |
1,753 |
$32K |
| D4341 |
|
400 |
115 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
1,524 |
1,501 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
100 |
51 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
62 |
14 |
$4K |
| D0272 |
Bitewings - two radiographic images |
136 |
135 |
$1K |
| D1351 |
Sealant - per tooth |
45 |
12 |
$871.20 |