| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,147 |
1,127 |
$70K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,546 |
1,518 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,072 |
1,059 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
370 |
362 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
326 |
316 |
$18K |
| D2750 |
|
19 |
12 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
26 |
$5K |
| D1351 |
Sealant - per tooth |
121 |
25 |
$4K |
| D1330 |
|
603 |
600 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
302 |
297 |
$3K |
| D1120 |
Prophylaxis - child |
40 |
40 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
137 |
136 |
$1K |
| D0274 |
Bitewings - four radiographic images |
43 |
42 |
$1K |