| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,515 |
3,512 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
5,821 |
5,820 |
$39K |
| D0274 |
Bitewings - four radiographic images |
3,219 |
3,218 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
6,531 |
6,511 |
$14K |
| D1120 |
Prophylaxis - child |
1,059 |
1,059 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,419 |
4,404 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
1,349 |
1,339 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,440 |
1,439 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
249 |
249 |
$2K |
| D0330 |
Panoramic radiographic image |
80 |
80 |
$1K |
| D0272 |
Bitewings - two radiographic images |
425 |
425 |
$1K |
| D1351 |
Sealant - per tooth |
12 |
12 |
$465.02 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$421.75 |