| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,419 |
1,402 |
$122K |
| D0120 |
Periodic oral evaluation - established patient |
1,694 |
1,671 |
$94K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
708 |
705 |
$46K |
| D0274 |
Bitewings - four radiographic images |
2,005 |
1,985 |
$42K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,711 |
2,715 |
$36K |
| D1120 |
Prophylaxis - child |
732 |
722 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,254 |
1,241 |
$16K |
| D4341 |
|
85 |
26 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
85 |
51 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
42 |
31 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
38 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
114 |
111 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$1K |