| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
114 |
113 |
$4K |
| D0274 |
Bitewings - four radiographic images |
124 |
122 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
150 |
148 |
$3K |
| D1351 |
Sealant - per tooth |
83 |
18 |
$2K |
| D1120 |
Prophylaxis - child |
50 |
49 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
63 |
63 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$548.10 |
| D0220 |
Intraoral - periapical first radiographic image |
44 |
44 |
$332.64 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$257.04 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$245.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
19 |
$189.00 |