| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
608 |
604 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
869 |
869 |
$26K |
| D1206 |
Topical application of fluoride varnish |
359 |
358 |
$11K |
| D1120 |
Prophylaxis - child |
171 |
171 |
$8K |
| D0274 |
Bitewings - four radiographic images |
390 |
390 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
104 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
529 |
516 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
180 |
176 |
$2K |
| D1351 |
Sealant - per tooth |
71 |
16 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
269 |
268 |
$933.00 |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$880.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
32 |
$775.00 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$250.00 |