| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,123 |
1,114 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,508 |
1,499 |
$45K |
| D1206 |
Topical application of fluoride varnish |
955 |
944 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
322 |
316 |
$14K |
| D1120 |
Prophylaxis - child |
296 |
296 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
197 |
196 |
$9K |
| D1351 |
Sealant - per tooth |
310 |
55 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,126 |
1,095 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
819 |
786 |
$3K |
| D0274 |
Bitewings - four radiographic images |
146 |
146 |
$2K |
| D0272 |
Bitewings - two radiographic images |
90 |
90 |
$900.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
18 |
$450.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$144.00 |