| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
884 |
878 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,125 |
1,116 |
$27K |
| D1206 |
Topical application of fluoride varnish |
612 |
605 |
$11K |
| D1120 |
Prophylaxis - child |
238 |
234 |
$7K |
| D0274 |
Bitewings - four radiographic images |
241 |
239 |
$7K |
| D1351 |
Sealant - per tooth |
169 |
29 |
$4K |
| D0330 |
Panoramic radiographic image |
106 |
106 |
$4K |
| D0272 |
Bitewings - two radiographic images |
221 |
219 |
$4K |
| D1330 |
|
306 |
306 |
$3K |
| D1310 |
|
190 |
190 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
49 |
$1K |
| D0603 |
|
112 |
112 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$386.77 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$91.69 |