| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
556 |
554 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
629 |
628 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,129 |
1,849 |
$37K |
| D9430 |
|
996 |
832 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
338 |
338 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
400 |
171 |
$22K |
| D0350 |
|
1,928 |
637 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,531 |
1,526 |
$18K |
| D4910 |
|
222 |
213 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,016 |
1,013 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
433 |
371 |
$5K |
| D4341 |
|
64 |
17 |
$4K |
| D2330 |
|
44 |
13 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
20 |
14 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
24 |
$2K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$1K |
| D1999 |
|
73 |
71 |
$40.00 |