| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,517 |
1,500 |
$49K |
| D1351 |
Sealant - per tooth |
1,105 |
236 |
$47K |
| D0210 |
Intraoral - complete series of radiographic images |
834 |
821 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,454 |
1,446 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,102 |
1,086 |
$21K |
| D0274 |
Bitewings - four radiographic images |
780 |
773 |
$20K |
| D1120 |
Prophylaxis - child |
794 |
790 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
340 |
235 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
267 |
175 |
$14K |
| D9110 |
|
406 |
398 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
431 |
431 |
$7K |
| D1206 |
Topical application of fluoride varnish |
352 |
350 |
$6K |
| D1330 |
|
986 |
982 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
531 |
519 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
82 |
81 |
$816.96 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$181.44 |