| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,887 |
1,884 |
$161K |
| D0120 |
Periodic oral evaluation - established patient |
2,741 |
2,734 |
$150K |
| D4910 |
|
1,528 |
1,520 |
$117K |
| D4341 |
|
1,615 |
459 |
$100K |
| D0230 |
Intraoral - periapical each additional radiographic image |
21,239 |
3,457 |
$80K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
790 |
374 |
$53K |
| D1206 |
Topical application of fluoride varnish |
3,526 |
3,519 |
$51K |
| D0274 |
Bitewings - four radiographic images |
2,239 |
2,238 |
$47K |
| D9430 |
|
1,410 |
1,264 |
$44K |
| D1120 |
Prophylaxis - child |
1,157 |
1,152 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
304 |
304 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
384 |
381 |
$18K |
| D2330 |
|
240 |
96 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
302 |
99 |
$16K |
| D2140 |
|
268 |
165 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,079 |
1,044 |
$12K |
| D2160 |
|
81 |
56 |
$6K |
| D1351 |
Sealant - per tooth |
195 |
44 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
27 |
$2K |
| D4342 |
|
42 |
15 |
$1K |
| D1320 |
|
43 |
43 |
$420.00 |
| D1999 |
|
25 |
25 |
$40.00 |