| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
545 |
524 |
$11K |
| D0330 |
Panoramic radiographic image |
263 |
256 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
708 |
682 |
$7K |
| D1351 |
Sealant - per tooth |
336 |
64 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
490 |
468 |
$3K |
| D0274 |
Bitewings - four radiographic images |
223 |
212 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
171 |
165 |
$3K |
| D1120 |
Prophylaxis - child |
219 |
212 |
$2K |
| D4355 |
|
28 |
28 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
154 |
148 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
80 |
76 |
$278.25 |
| D2160 |
|
16 |
13 |
$192.94 |
| D0230 |
Intraoral - periapical each additional radiographic image |
51 |
25 |
$130.00 |
| D9920 |
|
17 |
12 |
$93.50 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$74.43 |