| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,189 |
2,166 |
$121K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,953 |
1,928 |
$94K |
| D0210 |
Intraoral - complete series of radiographic images |
2,039 |
2,019 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
1,563 |
1,547 |
$50K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,345 |
1,338 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
314 |
154 |
$18K |
| D9430 |
|
405 |
387 |
$10K |
| D1206 |
Topical application of fluoride varnish |
615 |
612 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
173 |
94 |
$8K |
| D4341 |
|
182 |
52 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
748 |
720 |
$6K |
| D1120 |
Prophylaxis - child |
94 |
94 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
409 |
170 |
$2K |
| D4910 |
|
12 |
12 |
$929.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
26 |
14 |
$867.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$91.00 |