| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,222 |
1,206 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
1,550 |
1,543 |
$98K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,165 |
1,156 |
$73K |
| D1120 |
Prophylaxis - child |
1,261 |
1,257 |
$53K |
| D0210 |
Intraoral - complete series of radiographic images |
811 |
800 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,141 |
2,264 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,552 |
2,534 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,017 |
1,014 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,654 |
1,542 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
204 |
162 |
$13K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
193 |
138 |
$13K |
| D9430 |
|
333 |
331 |
$11K |
| D0350 |
|
682 |
412 |
$6K |
| D4910 |
|
38 |
38 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
25 |
$2K |
| D1206 |
Topical application of fluoride varnish |
100 |
98 |
$934.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
13 |
$764.40 |