| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,391 |
2,384 |
$214K |
| D0120 |
Periodic oral evaluation - established patient |
1,731 |
1,722 |
$137K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,805 |
1,804 |
$119K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,423 |
822 |
$95K |
| D0210 |
Intraoral - complete series of radiographic images |
1,661 |
1,660 |
$78K |
| D0350 |
|
7,244 |
2,626 |
$70K |
| D1206 |
Topical application of fluoride varnish |
3,399 |
3,386 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
789 |
433 |
$43K |
| D1120 |
Prophylaxis - child |
787 |
782 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,690 |
1,682 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,616 |
2,076 |
$31K |
| D2330 |
|
81 |
40 |
$6K |
| D4910 |
|
63 |
63 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
81 |
53 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$168.00 |