| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
243 |
236 |
$9K |
| D1351 |
Sealant - per tooth |
317 |
35 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
217 |
212 |
$4K |
| D1110 |
Prophylaxis - adult |
146 |
144 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
81 |
78 |
$1K |
| D1206 |
Topical application of fluoride varnish |
98 |
98 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
59 |
56 |
$667.85 |
| D1120 |
Prophylaxis - child |
19 |
19 |
$549.90 |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
65 |
$518.94 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$128.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$23.13 |