| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
809 |
804 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,024 |
1,020 |
$27K |
| D1110 |
Prophylaxis - adult |
392 |
392 |
$25K |
| D0330 |
Panoramic radiographic image |
85 |
85 |
$7K |
| D1351 |
Sealant - per tooth |
534 |
127 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
138 |
137 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,023 |
1,019 |
$2K |
| D0272 |
Bitewings - two radiographic images |
657 |
653 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
231 |
229 |
$1K |
| D1330 |
|
1,265 |
1,260 |
$588.66 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$266.11 |
| D0230 |
Intraoral - periapical each additional radiographic image |
116 |
44 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
130 |
129 |
$0.00 |