| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,068 |
1,064 |
$95K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
800 |
796 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
646 |
646 |
$50K |
| D4910 |
|
497 |
494 |
$38K |
| D0210 |
Intraoral - complete series of radiographic images |
730 |
726 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,182 |
1,178 |
$17K |
| D0274 |
Bitewings - four radiographic images |
668 |
667 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,898 |
1,062 |
$8K |
| D1120 |
Prophylaxis - child |
136 |
136 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
393 |
374 |
$5K |
| D1351 |
Sealant - per tooth |
96 |
15 |
$2K |
| D1206 |
Topical application of fluoride varnish |
66 |
66 |
$819.50 |
| D9430 |
|
18 |
13 |
$576.00 |