| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4346 |
|
356 |
344 |
$77K |
| D0272 |
Bitewings - two radiographic images |
1,857 |
1,751 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,358 |
1,280 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,292 |
1,778 |
$38K |
| D1110 |
Prophylaxis - adult |
765 |
731 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,390 |
1,323 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,423 |
1,344 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
2,079 |
1,934 |
$27K |
| D1351 |
Sealant - per tooth |
644 |
86 |
$19K |
| D1120 |
Prophylaxis - child |
490 |
479 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
95 |
92 |
$4K |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$622.50 |