| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
336 |
336 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
688 |
688 |
$26K |
| D4341 |
|
249 |
64 |
$17K |
| D4910 |
|
199 |
199 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
362 |
361 |
$15K |
| D1120 |
Prophylaxis - child |
437 |
437 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
199 |
199 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,457 |
323 |
$10K |
| D1351 |
Sealant - per tooth |
350 |
78 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
338 |
338 |
$4K |
| D2140 |
|
63 |
18 |
$3K |
| D1206 |
Topical application of fluoride varnish |
416 |
416 |
$3K |
| D0272 |
Bitewings - two radiographic images |
264 |
263 |
$3K |