| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,023 |
1,022 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
1,239 |
1,238 |
$64K |
| D9430 |
|
853 |
741 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
373 |
373 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
244 |
243 |
$15K |
| D1206 |
Topical application of fluoride varnish |
850 |
850 |
$14K |
| D0274 |
Bitewings - four radiographic images |
592 |
591 |
$12K |
| D1120 |
Prophylaxis - child |
321 |
321 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,703 |
1,244 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
880 |
874 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
121 |
61 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
139 |
58 |
$7K |
| D0350 |
|
523 |
190 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
177 |
172 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
14 |
13 |
$1K |