| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,474 |
1,473 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
2,581 |
2,579 |
$66K |
| D1120 |
Prophylaxis - child |
1,465 |
1,465 |
$56K |
| D1206 |
Topical application of fluoride varnish |
1,869 |
1,867 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
1,197 |
1,192 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
235 |
234 |
$17K |
| D0274 |
Bitewings - four radiographic images |
417 |
417 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
977 |
628 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
102 |
99 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
82 |
82 |
$4K |
| D1351 |
Sealant - per tooth |
99 |
13 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
60 |
60 |
$1K |