| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
495 |
437 |
$24K |
| D1351 |
Sealant - per tooth |
779 |
91 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
223 |
115 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
703 |
597 |
$16K |
| D0274 |
Bitewings - four radiographic images |
474 |
418 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
294 |
126 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
537 |
445 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
989 |
532 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
155 |
151 |
$9K |
| D1120 |
Prophylaxis - child |
323 |
253 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
199 |
187 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
595 |
543 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
62 |
62 |
$3K |