| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,034 |
1,029 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,988 |
1,978 |
$34K |
| D1120 |
Prophylaxis - child |
825 |
822 |
$26K |
| D1351 |
Sealant - per tooth |
371 |
86 |
$15K |
| D0272 |
Bitewings - two radiographic images |
653 |
651 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
489 |
487 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
74 |
73 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
54 |
$626.08 |