| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,773 |
405 |
$98K |
| D1110 |
Prophylaxis - adult |
2,170 |
2,162 |
$81K |
| D0140 |
Limited oral evaluation - problem focused |
1,960 |
1,875 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,993 |
1,987 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,111 |
1,106 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,105 |
1,104 |
$19K |
| D1120 |
Prophylaxis - child |
413 |
413 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,077 |
1,048 |
$11K |
| D1206 |
Topical application of fluoride varnish |
526 |
523 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
628 |
492 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
189 |
189 |
$4K |
| D0603 |
|
262 |
261 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$557.15 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$197.09 |
| D0601 |
|
13 |
13 |
$65.00 |