| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,032 |
2,032 |
$55K |
| D1120 |
Prophylaxis - child |
1,590 |
1,590 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,311 |
1,311 |
$18K |
| D1110 |
Prophylaxis - adult |
343 |
343 |
$17K |
| D0145 |
Oral evaluation for a patient under three years of age |
119 |
119 |
$17K |
| D0272 |
Bitewings - two radiographic images |
599 |
598 |
$13K |
| D1206 |
Topical application of fluoride varnish |
564 |
564 |
$8K |
| D0330 |
Panoramic radiographic image |
74 |
74 |
$4K |
| D1351 |
Sealant - per tooth |
111 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
56 |
56 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
75 |
75 |
$828.96 |
| D0603 |
|
2,324 |
2,318 |
$0.00 |
| D0601 |
|
79 |
79 |
$0.00 |