| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,848 |
1,227 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
2,407 |
1,681 |
$41K |
| D1351 |
Sealant - per tooth |
1,651 |
188 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,580 |
1,084 |
$24K |
| D0274 |
Bitewings - four radiographic images |
899 |
569 |
$24K |
| D1120 |
Prophylaxis - child |
825 |
593 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
267 |
169 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
199 |
138 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
52 |
36 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
112 |
79 |
$1K |