| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,875 |
1,840 |
$155K |
| D0120 |
Periodic oral evaluation - established patient |
1,590 |
1,576 |
$100K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,459 |
1,417 |
$87K |
| D0210 |
Intraoral - complete series of radiographic images |
1,242 |
1,205 |
$56K |
| D1206 |
Topical application of fluoride varnish |
2,868 |
2,813 |
$44K |
| D1120 |
Prophylaxis - child |
1,003 |
987 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
757 |
204 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
505 |
203 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,268 |
2,148 |
$21K |
| D0274 |
Bitewings - four radiographic images |
970 |
960 |
$19K |
| D4341 |
|
192 |
50 |
$13K |
| D2330 |
|
166 |
56 |
$13K |
| D9110 |
|
78 |
76 |
$5K |
| D9430 |
|
111 |
104 |
$3K |
| D1351 |
Sealant - per tooth |
182 |
37 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
172 |
169 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
14 |
$2K |
| D0272 |
Bitewings - two radiographic images |
113 |
113 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
96 |
89 |
$1K |