| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
225 |
217 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
139 |
125 |
$4K |
| D1206 |
Topical application of fluoride varnish |
118 |
114 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
173 |
169 |
$3K |
| D1351 |
Sealant - per tooth |
145 |
24 |
$3K |
| D1120 |
Prophylaxis - child |
59 |
56 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
181 |
172 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
60 |
52 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
145 |
88 |
$759.81 |
| D1110 |
Prophylaxis - adult |
27 |
25 |
$645.00 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$353.55 |