| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,835 |
1,818 |
$152K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,228 |
1,213 |
$77K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
624 |
343 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,644 |
1,133 |
$29K |
| D0330 |
Panoramic radiographic image |
803 |
788 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,772 |
1,715 |
$21K |
| D2330 |
|
212 |
134 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
153 |
147 |
$11K |
| D9430 |
|
267 |
260 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
40 |
25 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$209.00 |