| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
991 |
138 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,350 |
1,238 |
$23K |
| D1120 |
Prophylaxis - child |
789 |
736 |
$22K |
| D0274 |
Bitewings - four radiographic images |
495 |
451 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
674 |
625 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
126 |
117 |
$4K |
| D1110 |
Prophylaxis - adult |
94 |
88 |
$3K |
| D0330 |
Panoramic radiographic image |
14 |
12 |
$664.62 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$404.43 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
26 |
$370.98 |
| D1999 |
|
360 |
247 |
$0.00 |