| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,502 |
1,485 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
2,383 |
2,355 |
$70K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,226 |
2,201 |
$51K |
| D1120 |
Prophylaxis - child |
1,030 |
1,021 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
192 |
110 |
$23K |
| D0274 |
Bitewings - four radiographic images |
895 |
881 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
95 |
43 |
$9K |
| D0330 |
Panoramic radiographic image |
177 |
177 |
$8K |
| D1351 |
Sealant - per tooth |
123 |
28 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
73 |
$4K |
| D0272 |
Bitewings - two radiographic images |
75 |
72 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
74 |
70 |
$689.65 |