| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,570 |
1,569 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
1,246 |
1,245 |
$25K |
| D0274 |
Bitewings - four radiographic images |
1,074 |
1,074 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
307 |
130 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,411 |
1,410 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,782 |
1,775 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
272 |
272 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
408 |
408 |
$4K |
| D1351 |
Sealant - per tooth |
47 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$435.08 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$137.76 |