| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
438 |
437 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
620 |
620 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
319 |
316 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
439 |
438 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
287 |
287 |
$2K |
| D0274 |
Bitewings - four radiographic images |
284 |
284 |
$2K |
| D0330 |
Panoramic radiographic image |
92 |
92 |
$2K |
| D1351 |
Sealant - per tooth |
32 |
12 |
$643.76 |
| D1208 |
Topical application of fluoride, excluding varnish |
123 |
123 |
$625.32 |
| D1120 |
Prophylaxis - child |
19 |
19 |
$239.42 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
15 |
$168.61 |