| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
613 |
563 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
448 |
377 |
$26K |
| D1120 |
Prophylaxis - child |
432 |
397 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
90 |
72 |
$7K |
| D1206 |
Topical application of fluoride varnish |
422 |
388 |
$5K |
| D9110 |
|
50 |
38 |
$4K |
| D0330 |
Panoramic radiographic image |
112 |
107 |
$3K |
| D0274 |
Bitewings - four radiographic images |
66 |
60 |
$3K |
| D1351 |
Sealant - per tooth |
27 |
12 |
$2K |
| D2140 |
|
12 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
12 |
$1K |
| D0270 |
|
31 |
28 |
$1K |
| D0272 |
Bitewings - two radiographic images |
39 |
38 |
$564.70 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$213.70 |
| D0602 |
|
20 |
20 |
$0.00 |