| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
931 |
929 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
1,231 |
1,228 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
632 |
631 |
$9K |
| D1120 |
Prophylaxis - child |
588 |
587 |
$6K |
| D0274 |
Bitewings - four radiographic images |
1,002 |
1,002 |
$6K |
| D0330 |
Panoramic radiographic image |
282 |
282 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
613 |
612 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
557 |
557 |
$1K |
| D1351 |
Sealant - per tooth |
78 |
13 |
$840.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
277 |
277 |
$469.75 |
| D1999 |
|
600 |
588 |
$0.00 |
| D1330 |
|
132 |
130 |
$0.00 |