| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,048 |
2,048 |
$102K |
| D0120 |
Periodic oral evaluation - established patient |
3,063 |
3,063 |
$70K |
| D1206 |
Topical application of fluoride varnish |
3,277 |
3,277 |
$53K |
| D0274 |
Bitewings - four radiographic images |
1,866 |
1,866 |
$51K |
| D1120 |
Prophylaxis - child |
1,223 |
1,223 |
$43K |
| D0330 |
Panoramic radiographic image |
617 |
617 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
1,037 |
1,030 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
210 |
210 |
$8K |
| D0272 |
Bitewings - two radiographic images |
435 |
435 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
832 |
735 |
$7K |
| D1351 |
Sealant - per tooth |
223 |
60 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
38 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
27 |
$1K |