| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
216 |
216 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
472 |
472 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
237 |
237 |
$8K |
| D0274 |
Bitewings - four radiographic images |
274 |
274 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
649 |
645 |
$7K |
| D1120 |
Prophylaxis - child |
188 |
188 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
611 |
519 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
212 |
212 |
$4K |
| D0330 |
Panoramic radiographic image |
73 |
73 |
$3K |
| D0272 |
Bitewings - two radiographic images |
90 |
90 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
40 |
$1K |
| D1351 |
Sealant - per tooth |
50 |
15 |
$1K |