| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,037 |
1,011 |
$84K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,261 |
1,222 |
$75K |
| D0210 |
Intraoral - complete series of radiographic images |
935 |
917 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
450 |
445 |
$29K |
| D0350 |
|
2,820 |
870 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,099 |
1,092 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
256 |
126 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
155 |
84 |
$9K |
| D9430 |
|
241 |
220 |
$8K |
| D1120 |
Prophylaxis - child |
195 |
195 |
$7K |
| D0274 |
Bitewings - four radiographic images |
279 |
274 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,286 |
640 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
492 |
464 |
$5K |
| D4910 |
|
57 |
55 |
$4K |
| D4341 |
|
44 |
13 |
$3K |
| D1351 |
Sealant - per tooth |
65 |
12 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$177.00 |