| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,215 |
3,215 |
$125K |
| D0120 |
Periodic oral evaluation - established patient |
4,377 |
4,377 |
$89K |
| D1120 |
Prophylaxis - child |
2,097 |
2,097 |
$65K |
| D0274 |
Bitewings - four radiographic images |
2,569 |
2,568 |
$52K |
| D0220 |
Intraoral - periapical first radiographic image |
4,751 |
4,746 |
$48K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,607 |
2,607 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,357 |
4,357 |
$28K |
| D1351 |
Sealant - per tooth |
268 |
187 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
704 |
703 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
680 |
680 |
$14K |
| D2791 |
|
42 |
38 |
$14K |
| D0330 |
Panoramic radiographic image |
431 |
431 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
121 |
101 |
$10K |
| D2954 |
|
50 |
46 |
$6K |
| D0160 |
|
145 |
145 |
$3K |
| D0272 |
Bitewings - two radiographic images |
246 |
246 |
$3K |
| D1206 |
Topical application of fluoride varnish |
54 |
54 |
$1K |