| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,088 |
1,084 |
$36K |
| D1351 |
Sealant - per tooth |
1,403 |
245 |
$35K |
| D0330 |
Panoramic radiographic image |
755 |
753 |
$26K |
| D0274 |
Bitewings - four radiographic images |
898 |
895 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
971 |
967 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
706 |
704 |
$13K |
| D9110 |
|
389 |
388 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
484 |
484 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
814 |
804 |
$6K |
| D1120 |
Prophylaxis - child |
169 |
169 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
209 |
207 |
$2K |
| D0272 |
Bitewings - two radiographic images |
50 |
50 |
$779.04 |
| D1999 |
|
14 |
14 |
$0.00 |