| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
240 |
240 |
$8K |
| D1351 |
Sealant - per tooth |
286 |
43 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
283 |
282 |
$5K |
| D0274 |
Bitewings - four radiographic images |
204 |
204 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
259 |
259 |
$4K |
| D1120 |
Prophylaxis - child |
177 |
176 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
157 |
157 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
186 |
186 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
153 |
136 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
50 |
$797.40 |
| D0272 |
Bitewings - two radiographic images |
48 |
48 |
$742.40 |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$715.33 |