| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
258 |
255 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
310 |
307 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
61 |
60 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
388 |
383 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
434 |
298 |
$5K |
| D0272 |
Bitewings - two radiographic images |
211 |
209 |
$4K |
| D1110 |
Prophylaxis - adult |
75 |
73 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
335 |
328 |
$4K |
| D0274 |
Bitewings - four radiographic images |
107 |
105 |
$3K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$2K |
| D1351 |
Sealant - per tooth |
48 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$459.16 |
| D0603 |
|
495 |
494 |
$0.00 |