| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,859 |
199 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,565 |
1,276 |
$33K |
| D1120 |
Prophylaxis - child |
542 |
522 |
$23K |
| D0274 |
Bitewings - four radiographic images |
941 |
908 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
693 |
645 |
$21K |
| D1206 |
Topical application of fluoride varnish |
511 |
492 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
560 |
542 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,036 |
990 |
$14K |
| D1110 |
Prophylaxis - adult |
268 |
265 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
70 |
70 |
$2K |
| D0602 |
|
146 |
145 |
$688.40 |
| D1208 |
Topical application of fluoride, excluding varnish |
48 |
48 |
$491.28 |
| D0601 |
|
71 |
71 |
$355.00 |
| D4355 |
|
15 |
14 |
$245.00 |
| D9110 |
|
13 |
13 |
$204.00 |