| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,684 |
4,682 |
$204K |
| D0120 |
Periodic oral evaluation - established patient |
6,229 |
6,226 |
$136K |
| D0274 |
Bitewings - four radiographic images |
3,937 |
3,937 |
$86K |
| D9990 |
|
3,534 |
3,236 |
$78K |
| D0220 |
Intraoral - periapical first radiographic image |
6,280 |
6,228 |
$67K |
| D2750 |
|
89 |
79 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,233 |
3,231 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,213 |
5,211 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
335 |
267 |
$28K |
| D1120 |
Prophylaxis - child |
853 |
852 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
501 |
314 |
$26K |
| D9991 |
|
2,114 |
1,869 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
420 |
413 |
$15K |
| D0272 |
Bitewings - two radiographic images |
459 |
459 |
$6K |
| D9110 |
|
85 |
84 |
$2K |
| D1351 |
Sealant - per tooth |
15 |
15 |
$1K |