| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,506 |
1,502 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
1,991 |
1,989 |
$47K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,837 |
1,833 |
$45K |
| D1120 |
Prophylaxis - child |
423 |
423 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
209 |
114 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
315 |
315 |
$12K |
| D0274 |
Bitewings - four radiographic images |
644 |
644 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
988 |
978 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
794 |
791 |
$3K |
| D1351 |
Sealant - per tooth |
194 |
38 |
$2K |
| D9211 |
|
131 |
124 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
81 |
$2K |
| D0601 |
|
63 |
63 |
$661.50 |
| D9212 |
|
26 |
24 |
$657.50 |