| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,311 |
1,310 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
2,163 |
2,160 |
$55K |
| D1120 |
Prophylaxis - child |
1,195 |
1,194 |
$46K |
| D0220 |
Intraoral - periapical first radiographic image |
1,665 |
1,657 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,085 |
1,083 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,816 |
1,814 |
$23K |
| D1206 |
Topical application of fluoride varnish |
476 |
475 |
$13K |
| D1351 |
Sealant - per tooth |
339 |
108 |
$13K |
| D0272 |
Bitewings - two radiographic images |
439 |
439 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
118 |
118 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
24 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
193 |
192 |
$2K |