| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,828 |
3,827 |
$160K |
| D0274 |
Bitewings - four radiographic images |
3,890 |
3,889 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
3,751 |
3,751 |
$82K |
| D0220 |
Intraoral - periapical first radiographic image |
5,142 |
5,136 |
$54K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,978 |
4,977 |
$47K |
| D1120 |
Prophylaxis - child |
1,053 |
1,053 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,365 |
1,364 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,362 |
2,362 |
$26K |
| D1351 |
Sealant - per tooth |
332 |
182 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
272 |
146 |
$9K |
| D0272 |
Bitewings - two radiographic images |
435 |
435 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
100 |
65 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
579 |
575 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
28 |
25 |
$2K |