| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,265 |
1,192 |
$71K |
| D1120 |
Prophylaxis - child |
1,227 |
1,181 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
2,186 |
2,089 |
$56K |
| D1206 |
Topical application of fluoride varnish |
2,305 |
2,200 |
$55K |
| D0274 |
Bitewings - four radiographic images |
718 |
681 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
862 |
805 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
491 |
462 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
25 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
46 |
40 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
46 |
45 |
$2K |
| D1351 |
Sealant - per tooth |
38 |
13 |
$1K |