| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
737 |
737 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
969 |
969 |
$26K |
| D1206 |
Topical application of fluoride varnish |
540 |
539 |
$19K |
| D1120 |
Prophylaxis - child |
314 |
314 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
214 |
214 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
757 |
756 |
$4K |
| D0274 |
Bitewings - four radiographic images |
302 |
301 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
583 |
582 |
$3K |
| D1351 |
Sealant - per tooth |
70 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$972.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$648.00 |