| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
317 |
317 |
$8K |
| D1120 |
Prophylaxis - child |
110 |
110 |
$5K |
| D1110 |
Prophylaxis - adult |
146 |
146 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
114 |
114 |
$3K |
| D0330 |
Panoramic radiographic image |
96 |
96 |
$2K |
| D1351 |
Sealant - per tooth |
80 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
49 |
$1K |
| D0274 |
Bitewings - four radiographic images |
81 |
81 |
$972.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$375.00 |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
68 |
$345.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
32 |
$174.00 |