| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
8,828 |
8,825 |
$375K |
| D0120 |
Periodic oral evaluation - established patient |
10,597 |
10,591 |
$235K |
| D0274 |
Bitewings - four radiographic images |
10,277 |
10,275 |
$219K |
| D0220 |
Intraoral - periapical first radiographic image |
11,147 |
11,100 |
$117K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,574 |
10,549 |
$55K |
| D1120 |
Prophylaxis - child |
1,252 |
1,250 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,136 |
3,135 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
513 |
329 |
$33K |
| D4341 |
|
384 |
232 |
$32K |
| D7140 |
Extraction, erupted tooth or exposed root |
712 |
535 |
$31K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
469 |
399 |
$28K |
| D2954 |
|
174 |
151 |
$19K |
| D1206 |
Topical application of fluoride varnish |
177 |
177 |
$5K |
| D1351 |
Sealant - per tooth |
32 |
29 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
43 |
$3K |
| D2330 |
|
47 |
41 |
$3K |
| D9110 |
|
156 |
152 |
$3K |
| D2160 |
|
14 |
14 |
$1K |
| D2140 |
|
15 |
14 |
$785.52 |