| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
750 |
747 |
$27K |
| D0274 |
Bitewings - four radiographic images |
634 |
632 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
817 |
814 |
$16K |
| D1351 |
Sealant - per tooth |
463 |
63 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
407 |
407 |
$8K |
| D1120 |
Prophylaxis - child |
197 |
197 |
$6K |
| D0330 |
Panoramic radiographic image |
141 |
140 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
230 |
229 |
$5K |
| D0272 |
Bitewings - two radiographic images |
55 |
55 |
$909.95 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$250.00 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$192.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$104.00 |