| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
927 |
852 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
661 |
593 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
441 |
392 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
816 |
762 |
$21K |
| D1120 |
Prophylaxis - child |
326 |
325 |
$12K |
| D0274 |
Bitewings - four radiographic images |
293 |
268 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
32 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
247 |
246 |
$5K |
| D0272 |
Bitewings - two radiographic images |
105 |
105 |
$2K |
| D1351 |
Sealant - per tooth |
56 |
14 |
$1K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$291.48 |