| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
175 |
153 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
190 |
168 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
103 |
$2K |
| D1351 |
Sealant - per tooth |
69 |
30 |
$1K |
| D1206 |
Topical application of fluoride varnish |
86 |
71 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
91 |
90 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
48 |
46 |
$1K |
| D0330 |
Panoramic radiographic image |
44 |
44 |
$881.40 |
| D0220 |
Intraoral - periapical first radiographic image |
118 |
118 |
$655.20 |
| D9310 |
|
33 |
33 |
$547.20 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$413.10 |
| D0602 |
|
15 |
12 |
$0.00 |
| D0601 |
|
47 |
35 |
$0.00 |