| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
696 |
690 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,210 |
1,195 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,318 |
1,301 |
$30K |
| D1120 |
Prophylaxis - child |
537 |
526 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
73 |
39 |
$9K |
| D0274 |
Bitewings - four radiographic images |
364 |
360 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
884 |
861 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
127 |
124 |
$7K |
| D1351 |
Sealant - per tooth |
157 |
26 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
732 |
717 |
$5K |
| D1330 |
|
749 |
737 |
$4K |
| D1206 |
Topical application of fluoride varnish |
141 |
137 |
$3K |
| D0330 |
Panoramic radiographic image |
72 |
72 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
38 |
$2K |