| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
474 |
472 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
503 |
503 |
$15K |
| D1206 |
Topical application of fluoride varnish |
234 |
234 |
$7K |
| D0330 |
Panoramic radiographic image |
141 |
141 |
$6K |
| D1120 |
Prophylaxis - child |
84 |
84 |
$4K |
| D0274 |
Bitewings - four radiographic images |
233 |
233 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$2K |
| D1351 |
Sealant - per tooth |
51 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
65 |
65 |
$756.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
29 |
$725.00 |
| D0220 |
Intraoral - periapical first radiographic image |
107 |
102 |
$535.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$150.00 |