| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,010 |
2,010 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
2,479 |
2,476 |
$50K |
| D0274 |
Bitewings - four radiographic images |
1,872 |
1,872 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
2,233 |
2,230 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,016 |
2,013 |
$17K |
| D1120 |
Prophylaxis - child |
394 |
393 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
136 |
100 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
566 |
565 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
492 |
491 |
$5K |
| D1351 |
Sealant - per tooth |
16 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
197 |
196 |
$2K |
| D2330 |
|
27 |
17 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$591.52 |