| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
1,013 |
1,012 |
$103K |
| D1110 |
Prophylaxis - adult |
1,923 |
1,916 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
1,324 |
1,317 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,246 |
1,245 |
$21K |
| D1351 |
Sealant - per tooth |
4,026 |
831 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
228 |
105 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,486 |
2,479 |
$9K |
| D1120 |
Prophylaxis - child |
511 |
510 |
$4K |
| D0274 |
Bitewings - four radiographic images |
717 |
713 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
1,090 |
1,071 |
$1K |
| D1330 |
|
2,194 |
2,188 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
912 |
890 |
$767.13 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$156.00 |