| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,038 |
1,037 |
$56K |
| D1351 |
Sealant - per tooth |
1,994 |
384 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,658 |
1,658 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,466 |
1,466 |
$39K |
| D1120 |
Prophylaxis - child |
864 |
864 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,983 |
1,982 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
213 |
213 |
$15K |
| D2140 |
|
86 |
46 |
$5K |
| D0272 |
Bitewings - two radiographic images |
123 |
123 |
$2K |
| D0330 |
Panoramic radiographic image |
293 |
293 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
35 |
35 |
$1K |
| D0602 |
|
1,437 |
1,433 |
$0.00 |
| D0601 |
|
421 |
421 |
$0.00 |
| D0603 |
|
12 |
12 |
$0.00 |