| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
600 |
598 |
$53K |
| D4910 |
|
682 |
680 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
710 |
708 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
690 |
687 |
$45K |
| D1206 |
Topical application of fluoride varnish |
1,611 |
1,604 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
341 |
202 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,461 |
1,192 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
305 |
152 |
$17K |
| D0274 |
Bitewings - four radiographic images |
688 |
686 |
$15K |
| D1120 |
Prophylaxis - child |
288 |
284 |
$14K |
| D0350 |
|
660 |
313 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
112 |
112 |
$5K |
| D4341 |
|
50 |
13 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
278 |
272 |
$3K |
| D1351 |
Sealant - per tooth |
75 |
15 |
$3K |
| D9430 |
|
69 |
64 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
64 |
64 |
$734.50 |
| D1310 |
|
14 |
14 |
$598.00 |