| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
706 |
697 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,297 |
1,282 |
$35K |
| D0274 |
Bitewings - four radiographic images |
801 |
790 |
$26K |
| D0350 |
|
1,190 |
1,177 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,187 |
1,175 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
213 |
97 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,316 |
1,301 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,299 |
1,275 |
$14K |
| D1351 |
Sealant - per tooth |
496 |
81 |
$12K |
| D0460 |
|
915 |
898 |
$10K |
| D1120 |
Prophylaxis - child |
323 |
322 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
113 |
66 |
$10K |
| D0272 |
Bitewings - two radiographic images |
187 |
186 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$953.64 |
| D0603 |
|
1,493 |
1,463 |
$0.00 |