| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,043 |
992 |
$28K |
| D1110 |
Prophylaxis - adult |
525 |
503 |
$26K |
| D1120 |
Prophylaxis - child |
675 |
645 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,375 |
1,308 |
$19K |
| D0274 |
Bitewings - four radiographic images |
513 |
484 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,117 |
1,055 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,127 |
1,045 |
$12K |
| D1351 |
Sealant - per tooth |
234 |
67 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
150 |
142 |
$5K |
| D0272 |
Bitewings - two radiographic images |
155 |
149 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
40 |
$3K |
| D0603 |
|
1,292 |
1,248 |
$0.00 |
| D0601 |
|
201 |
195 |
$0.00 |
| D1999 |
|
149 |
128 |
$0.00 |