| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,111 |
1,106 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,241 |
1,240 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
872 |
866 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,516 |
1,501 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
596 |
595 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,272 |
1,253 |
$11K |
| D1120 |
Prophylaxis - child |
352 |
349 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
628 |
624 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
28 |
$2K |
| D1351 |
Sealant - per tooth |
33 |
15 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
26 |
$426.40 |
| D0140 |
Limited oral evaluation - problem focused |
41 |
40 |
$360.15 |