| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
384 |
381 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
425 |
420 |
$10K |
| D0274 |
Bitewings - four radiographic images |
272 |
271 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
187 |
181 |
$8K |
| D1120 |
Prophylaxis - child |
150 |
150 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
152 |
150 |
$7K |
| D1351 |
Sealant - per tooth |
118 |
29 |
$5K |
| D1206 |
Topical application of fluoride varnish |
160 |
159 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
240 |
230 |
$4K |
| D0330 |
Panoramic radiographic image |
50 |
49 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
22 |
17 |
$293.00 |