| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
350 |
350 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
376 |
376 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
411 |
408 |
$6K |
| D0274 |
Bitewings - four radiographic images |
150 |
150 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
112 |
112 |
$3K |
| D1120 |
Prophylaxis - child |
70 |
70 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
186 |
186 |
$3K |
| D1351 |
Sealant - per tooth |
24 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
117 |
117 |
$1K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$224.90 |