| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,936 |
3,907 |
$184K |
| D0140 |
Limited oral evaluation - problem focused |
3,019 |
2,978 |
$107K |
| D0120 |
Periodic oral evaluation - established patient |
3,539 |
3,512 |
$85K |
| D0220 |
Intraoral - periapical first radiographic image |
6,745 |
6,286 |
$85K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,185 |
5,811 |
$80K |
| D0274 |
Bitewings - four radiographic images |
2,094 |
2,088 |
$62K |
| D0180 |
|
150 |
150 |
$7K |
| D1351 |
Sealant - per tooth |
51 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
74 |
67 |
$857.86 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$696.92 |