| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
795 |
726 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,044 |
951 |
$24K |
| D1351 |
Sealant - per tooth |
563 |
71 |
$16K |
| D1206 |
Topical application of fluoride varnish |
786 |
723 |
$15K |
| D1120 |
Prophylaxis - child |
444 |
408 |
$14K |
| D0330 |
Panoramic radiographic image |
194 |
191 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
151 |
148 |
$5K |
| D0274 |
Bitewings - four radiographic images |
132 |
128 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
130 |
121 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
47 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
19 |
18 |
$313.50 |
| D0190 |
|
13 |
13 |
$0.00 |