| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
972 |
966 |
$56K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,120 |
1,062 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
61 |
61 |
$5K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$2K |
| D1351 |
Sealant - per tooth |
237 |
64 |
$835.76 |
| D0274 |
Bitewings - four radiographic images |
784 |
778 |
$341.95 |
| D0220 |
Intraoral - periapical first radiographic image |
1,108 |
1,091 |
$92.41 |
| D1330 |
|
966 |
962 |
$90.77 |
| D1208 |
Topical application of fluoride, excluding varnish |
963 |
956 |
$65.68 |
| D0120 |
Periodic oral evaluation - established patient |
920 |
915 |
$54.29 |
| D0272 |
Bitewings - two radiographic images |
78 |
76 |
$23.44 |