| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
674 |
631 |
$48K |
| D0210 |
Intraoral - complete series of radiographic images |
121 |
114 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
786 |
729 |
$15K |
| D1120 |
Prophylaxis - child |
426 |
396 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
27 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
192 |
181 |
$3K |
| D1351 |
Sealant - per tooth |
556 |
154 |
$597.66 |
| D1208 |
Topical application of fluoride, excluding varnish |
650 |
600 |
$159.52 |
| D0272 |
Bitewings - two radiographic images |
220 |
204 |
$57.86 |
| D1330 |
|
646 |
601 |
$43.00 |
| D0274 |
Bitewings - four radiographic images |
555 |
519 |
$20.44 |