| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,918 |
1,917 |
$69K |
| D1110 |
Prophylaxis - adult |
1,331 |
1,313 |
$63K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,238 |
2,237 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,393 |
1,390 |
$35K |
| D0274 |
Bitewings - four radiographic images |
857 |
856 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
151 |
148 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
27 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
52 |
52 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
102 |
101 |
$2K |
| D1351 |
Sealant - per tooth |
41 |
12 |
$845.35 |