| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,077 |
3,074 |
$129K |
| D0120 |
Periodic oral evaluation - established patient |
3,080 |
3,075 |
$67K |
| D0274 |
Bitewings - four radiographic images |
3,077 |
3,075 |
$67K |
| D0220 |
Intraoral - periapical first radiographic image |
3,317 |
3,310 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,166 |
3,165 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
561 |
559 |
$21K |
| D1120 |
Prophylaxis - child |
582 |
581 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,248 |
1,245 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
568 |
568 |
$14K |
| D1351 |
Sealant - per tooth |
45 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
24 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$269.75 |