| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
836 |
757 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
847 |
748 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
989 |
881 |
$11K |
| D1351 |
Sealant - per tooth |
499 |
76 |
$7K |
| D1110 |
Prophylaxis - adult |
160 |
136 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
120 |
$4K |
| D0272 |
Bitewings - two radiographic images |
148 |
139 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
59 |
53 |
$2K |
| D3910 |
|
196 |
25 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$332.26 |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
26 |
$172.06 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
12 |
$60.00 |
| D1999 |
|
16 |
16 |
$0.00 |
| D0603 |
|
228 |
199 |
$0.00 |
| D0601 |
|
344 |
312 |
$0.00 |
| D0602 |
|
406 |
373 |
$0.00 |