| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
985 |
982 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
1,698 |
1,692 |
$71K |
| D1120 |
Prophylaxis - child |
1,144 |
1,141 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
726 |
726 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
460 |
460 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,268 |
2,258 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
2,115 |
1,586 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,517 |
1,707 |
$19K |
| D9430 |
|
539 |
410 |
$17K |
| D0272 |
Bitewings - two radiographic images |
1,417 |
1,414 |
$16K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
246 |
177 |
$16K |
| D4341 |
|
212 |
58 |
$15K |
| D1351 |
Sealant - per tooth |
479 |
109 |
$10K |
| D9110 |
|
76 |
59 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
36 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
15 |
$1K |
| D1320 |
|
53 |
53 |
$490.00 |
| D9920 |
|
52 |
38 |
$140.00 |