| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,536 |
4,533 |
$166K |
| D0330 |
Panoramic radiographic image |
3,199 |
3,197 |
$90K |
| D0120 |
Periodic oral evaluation - established patient |
3,984 |
3,980 |
$78K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,450 |
2,448 |
$53K |
| D1120 |
Prophylaxis - child |
1,342 |
1,340 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,904 |
1,902 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,501 |
1,498 |
$17K |
| D2140 |
|
384 |
218 |
$16K |
| D1351 |
Sealant - per tooth |
324 |
135 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
744 |
735 |
$7K |
| D4341 |
|
68 |
25 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
638 |
633 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
173 |
172 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$708.25 |