| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,762 |
2,581 |
$154K |
| D1120 |
Prophylaxis - child |
2,980 |
2,743 |
$138K |
| D0120 |
Periodic oral evaluation - established patient |
5,037 |
4,677 |
$127K |
| D0272 |
Bitewings - two radiographic images |
4,433 |
4,132 |
$116K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,324 |
4,004 |
$105K |
| D0220 |
Intraoral - periapical first radiographic image |
4,978 |
4,617 |
$85K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,212 |
4,395 |
$70K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
900 |
419 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
420 |
392 |
$18K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
26 |
15 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
67 |
$9K |
| D1351 |
Sealant - per tooth |
223 |
65 |
$7K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$393.00 |