| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,621 |
1,613 |
$50K |
| D0274 |
Bitewings - four radiographic images |
1,236 |
1,226 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,464 |
1,455 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,166 |
1,162 |
$20K |
| D1206 |
Topical application of fluoride varnish |
603 |
597 |
$11K |
| D1110 |
Prophylaxis - adult |
112 |
108 |
$5K |
| D0272 |
Bitewings - two radiographic images |
206 |
205 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
73 |
$2K |
| D1351 |
Sealant - per tooth |
100 |
28 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
204 |
198 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
55 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
44 |
43 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
44 |
28 |
$352.68 |