| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,124 |
1,123 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,260 |
1,258 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,099 |
1,098 |
$29K |
| D1351 |
Sealant - per tooth |
248 |
120 |
$19K |
| D0274 |
Bitewings - four radiographic images |
735 |
735 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,234 |
1,230 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,100 |
1,100 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
143 |
143 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
51 |
$994.24 |
| D0272 |
Bitewings - two radiographic images |
71 |
71 |
$765.21 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$628.94 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$373.38 |