| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,237 |
1,184 |
$57K |
| D1206 |
Topical application of fluoride varnish |
1,526 |
1,467 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
602 |
569 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
869 |
843 |
$35K |
| D0272 |
Bitewings - two radiographic images |
843 |
809 |
$28K |
| D1110 |
Prophylaxis - adult |
321 |
314 |
$24K |
| D0330 |
Panoramic radiographic image |
216 |
216 |
$21K |
| D0274 |
Bitewings - four radiographic images |
133 |
131 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
87 |
84 |
$5K |
| D0240 |
|
88 |
52 |
$4K |
| D1351 |
Sealant - per tooth |
46 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
46 |
46 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$793.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
12 |
$787.00 |