| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,367 |
2,355 |
$208K |
| D0120 |
Periodic oral evaluation - established patient |
2,641 |
2,628 |
$176K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,382 |
2,378 |
$156K |
| D1120 |
Prophylaxis - child |
2,160 |
2,156 |
$90K |
| D0210 |
Intraoral - complete series of radiographic images |
1,749 |
1,746 |
$83K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,621 |
3,530 |
$47K |
| D0274 |
Bitewings - four radiographic images |
2,150 |
2,139 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,979 |
1,976 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,034 |
1,033 |
$12K |
| D1206 |
Topical application of fluoride varnish |
625 |
624 |
$11K |
| D9430 |
|
338 |
332 |
$11K |
| D1351 |
Sealant - per tooth |
282 |
71 |
$9K |
| D1320 |
|
375 |
374 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
27 |
14 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
28 |
$3K |
| D0350 |
|
76 |
39 |
$720.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |