| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,376 |
1,374 |
$61K |
| D1206 |
Topical application of fluoride varnish |
1,376 |
1,371 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,502 |
1,498 |
$37K |
| D1110 |
Prophylaxis - adult |
637 |
636 |
$28K |
| D1351 |
Sealant - per tooth |
1,245 |
200 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
380 |
362 |
$16K |
| D0330 |
Panoramic radiographic image |
299 |
299 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
442 |
441 |
$11K |
| D0274 |
Bitewings - four radiographic images |
656 |
652 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
143 |
142 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
463 |
444 |
$2K |
| D0272 |
Bitewings - two radiographic images |
99 |
99 |
$920.00 |
| D0601 |
|
27 |
27 |
$270.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
60 |
60 |
$261.00 |
| D0602 |
|
14 |
14 |
$140.00 |