| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,658 |
2,400 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
3,257 |
2,974 |
$56K |
| D1120 |
Prophylaxis - child |
768 |
707 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
989 |
910 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
138 |
79 |
$7K |
| D0274 |
Bitewings - four radiographic images |
306 |
294 |
$7K |
| D1351 |
Sealant - per tooth |
227 |
57 |
$5K |
| D0272 |
Bitewings - two radiographic images |
199 |
168 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
26 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
267 |
247 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
44 |
26 |
$354.50 |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$252.00 |