| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
87 |
81 |
$3K |
| D1120 |
Prophylaxis - child |
81 |
68 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
115 |
99 |
$3K |
| D1351 |
Sealant - per tooth |
32 |
19 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
96 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
90 |
78 |
$2K |
| D0274 |
Bitewings - four radiographic images |
95 |
82 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
209 |
185 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
19 |
19 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
210 |
166 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$246.70 |