| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,377 |
1,364 |
$88K |
| D0274 |
Bitewings - four radiographic images |
159 |
159 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
1,667 |
1,654 |
$10K |
| D1110 |
Prophylaxis - adult |
210 |
210 |
$5K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$746.22 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,563 |
1,553 |
$574.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,458 |
1,362 |
$408.76 |
| D0272 |
Bitewings - two radiographic images |
809 |
799 |
$376.00 |
| D0220 |
Intraoral - periapical first radiographic image |
1,545 |
1,520 |
$210.43 |
| D1351 |
Sealant - per tooth |
798 |
148 |
$0.00 |