| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,320 |
1,222 |
$37K |
| D1206 |
Topical application of fluoride varnish |
1,066 |
991 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
627 |
584 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
415 |
367 |
$13K |
| D0274 |
Bitewings - four radiographic images |
210 |
200 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
68 |
63 |
$3K |
| D1351 |
Sealant - per tooth |
126 |
24 |
$2K |
| D0330 |
Panoramic radiographic image |
46 |
41 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
67 |
66 |
$970.89 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$561.06 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
13 |
$290.52 |
| D1999 |
|
219 |
191 |
$0.00 |