| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
219 |
211 |
$14K |
| D1110 |
Prophylaxis - adult |
72 |
69 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
42 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
239 |
229 |
$123.00 |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
50 |
$15.00 |
| D0274 |
Bitewings - four radiographic images |
71 |
68 |
$0.00 |
| D1330 |
|
293 |
282 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
36 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
160 |
154 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
293 |
282 |
$0.00 |
| D1351 |
Sealant - per tooth |
65 |
16 |
$0.00 |