| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,028 |
888 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,617 |
1,319 |
$38K |
| D0330 |
Panoramic radiographic image |
523 |
461 |
$30K |
| D1120 |
Prophylaxis - child |
703 |
554 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
375 |
339 |
$12K |
| D0274 |
Bitewings - four radiographic images |
328 |
296 |
$11K |
| D1206 |
Topical application of fluoride varnish |
547 |
457 |
$10K |
| D1351 |
Sealant - per tooth |
70 |
15 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
57 |
45 |
$1K |
| D0272 |
Bitewings - two radiographic images |
28 |
25 |
$687.50 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$462.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$214.50 |
| D1999 |
|
314 |
185 |
$0.00 |