| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,397 |
1,322 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
1,626 |
1,535 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
174 |
164 |
$20K |
| D1120 |
Prophylaxis - child |
968 |
926 |
$19K |
| D1351 |
Sealant - per tooth |
1,845 |
456 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
512 |
490 |
$8K |
| D1206 |
Topical application of fluoride varnish |
2,085 |
1,986 |
$6K |
| D1330 |
|
2,328 |
2,214 |
$2K |
| D0330 |
Panoramic radiographic image |
40 |
40 |
$2K |
| D0274 |
Bitewings - four radiographic images |
1,027 |
970 |
$2K |
| D0272 |
Bitewings - two radiographic images |
374 |
358 |
$583.21 |
| D9986 |
|
18 |
18 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
16 |
$0.00 |