| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
787 |
775 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,232 |
1,208 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,026 |
1,828 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,566 |
1,540 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
526 |
510 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
799 |
791 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
427 |
417 |
$14K |
| D1351 |
Sealant - per tooth |
325 |
108 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
534 |
522 |
$5K |
| D1110 |
Prophylaxis - adult |
195 |
192 |
$4K |
| D2140 |
|
32 |
16 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
19 |
18 |
$1K |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$525.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
16 |
16 |
$480.00 |