| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,443 |
1,443 |
$125K |
| D0120 |
Periodic oral evaluation - established patient |
2,019 |
2,019 |
$111K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,456 |
1,991 |
$50K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,881 |
2,880 |
$37K |
| D0272 |
Bitewings - two radiographic images |
1,446 |
1,443 |
$17K |
| D1120 |
Prophylaxis - child |
395 |
395 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
193 |
193 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
202 |
202 |
$10K |
| D4341 |
|
88 |
24 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
26 |
$3K |
| D4910 |
|
29 |
29 |
$2K |
| D1351 |
Sealant - per tooth |
55 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
37 |
$456.00 |