| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
952 |
924 |
$26K |
| D1120 |
Prophylaxis - child |
567 |
542 |
$23K |
| D1206 |
Topical application of fluoride varnish |
426 |
405 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
601 |
561 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
145 |
136 |
$3K |
| D0274 |
Bitewings - four radiographic images |
159 |
155 |
$3K |
| D1351 |
Sealant - per tooth |
18 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
449 |
430 |
$2K |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$2K |
| D0330 |
Panoramic radiographic image |
75 |
74 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
81 |
81 |
$816.48 |