| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,396 |
1,394 |
$116K |
| D0120 |
Periodic oral evaluation - established patient |
1,801 |
1,799 |
$93K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
894 |
893 |
$54K |
| D0210 |
Intraoral - complete series of radiographic images |
1,090 |
1,089 |
$50K |
| D1120 |
Prophylaxis - child |
1,048 |
1,046 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,403 |
1,549 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,331 |
1,329 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,425 |
1,424 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
999 |
997 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
120 |
65 |
$8K |
| D1351 |
Sealant - per tooth |
119 |
39 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
16 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$1K |