| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
182 |
178 |
$10K |
| D1351 |
Sealant - per tooth |
448 |
61 |
$9K |
| D1206 |
Topical application of fluoride varnish |
230 |
223 |
$7K |
| D1120 |
Prophylaxis - child |
117 |
114 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
232 |
221 |
$4K |
| D1110 |
Prophylaxis - adult |
100 |
94 |
$3K |
| D0274 |
Bitewings - four radiographic images |
121 |
115 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
229 |
215 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
64 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
46 |
43 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
220 |
142 |
$1K |