| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,768 |
1,756 |
$74K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,114 |
3,098 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
2,688 |
2,672 |
$49K |
| D1120 |
Prophylaxis - child |
1,432 |
1,425 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,631 |
1,621 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
1,549 |
1,530 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,384 |
1,362 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
399 |
396 |
$13K |
| D1351 |
Sealant - per tooth |
172 |
54 |
$6K |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
16 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
14 |
$2K |
| D9630 |
|
28 |
28 |
$556.36 |