| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
210 |
205 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
201 |
188 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
240 |
229 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
188 |
182 |
$4K |
| D0274 |
Bitewings - four radiographic images |
265 |
246 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
410 |
378 |
$2K |
| D1351 |
Sealant - per tooth |
13 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
349 |
316 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
132 |
129 |
$1K |
| D0330 |
Panoramic radiographic image |
38 |
33 |
$361.60 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$194.40 |