| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
319 |
319 |
$11K |
| D0274 |
Bitewings - four radiographic images |
360 |
360 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
345 |
345 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
205 |
205 |
$5K |
| D1206 |
Topical application of fluoride varnish |
263 |
263 |
$5K |
| D1120 |
Prophylaxis - child |
174 |
174 |
$4K |
| D1351 |
Sealant - per tooth |
169 |
36 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
312 |
309 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
216 |
197 |
$2K |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$366.94 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$227.48 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$199.04 |