| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
788 |
741 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
784 |
751 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,731 |
858 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,201 |
1,091 |
$18K |
| D0274 |
Bitewings - four radiographic images |
655 |
601 |
$16K |
| D1351 |
Sealant - per tooth |
432 |
83 |
$12K |
| D1206 |
Topical application of fluoride varnish |
172 |
162 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
106 |
$4K |
| D0330 |
Panoramic radiographic image |
77 |
71 |
$4K |
| D1120 |
Prophylaxis - child |
73 |
73 |
$3K |
| D0272 |
Bitewings - two radiographic images |
153 |
151 |
$2K |
| D9110 |
|
16 |
12 |
$918.97 |
| D1330 |
|
139 |
121 |
$841.11 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$603.35 |
| D9211 |
|
122 |
71 |
$0.00 |