| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,551 |
2,533 |
$213K |
| D0120 |
Periodic oral evaluation - established patient |
3,230 |
3,210 |
$190K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,081 |
2,070 |
$128K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,664 |
1,082 |
$110K |
| D1120 |
Prophylaxis - child |
2,643 |
2,630 |
$106K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,952 |
1,121 |
$105K |
| D0210 |
Intraoral - complete series of radiographic images |
1,911 |
1,906 |
$89K |
| D4341 |
|
1,002 |
279 |
$70K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,931 |
4,903 |
$64K |
| D0274 |
Bitewings - four radiographic images |
3,192 |
3,178 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,225 |
4,552 |
$40K |
| D9430 |
|
1,248 |
1,195 |
$39K |
| D4910 |
|
501 |
499 |
$39K |
| D0350 |
|
4,662 |
2,259 |
$37K |
| D1351 |
Sealant - per tooth |
503 |
120 |
$15K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
124 |
82 |
$15K |
| D4342 |
|
83 |
25 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
726 |
722 |
$2K |
| D0330 |
Panoramic radiographic image |
53 |
53 |
$1K |
| D0272 |
Bitewings - two radiographic images |
100 |
98 |
$1K |
| D0270 |
|
98 |
98 |
$460.00 |
| D3120 |
|
12 |
12 |
$0.00 |