| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,114 |
3,110 |
$123K |
| D0120 |
Periodic oral evaluation - established patient |
5,774 |
5,771 |
$121K |
| D1120 |
Prophylaxis - child |
2,602 |
2,602 |
$82K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,977 |
2,977 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,287 |
1,286 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,653 |
1,653 |
$16K |
| D1351 |
Sealant - per tooth |
295 |
166 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
123 |
64 |
$10K |
| D0272 |
Bitewings - two radiographic images |
711 |
711 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
55 |
55 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
14 |
$995.50 |