| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
649 |
642 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,089 |
1,079 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,236 |
1,212 |
$27K |
| D1120 |
Prophylaxis - child |
456 |
443 |
$18K |
| D0274 |
Bitewings - four radiographic images |
425 |
420 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
587 |
575 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
941 |
473 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
24 |
$5K |
| D0330 |
Panoramic radiographic image |
81 |
79 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
117 |
115 |
$5K |
| D1351 |
Sealant - per tooth |
42 |
14 |
$1K |