| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,709 |
4,677 |
$233K |
| D1120 |
Prophylaxis - child |
5,536 |
5,498 |
$192K |
| D1351 |
Sealant - per tooth |
1,920 |
556 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
619 |
616 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,954 |
2,931 |
$31K |
| D1206 |
Topical application of fluoride varnish |
2,232 |
2,213 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
579 |
577 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,613 |
1,597 |
$18K |
| D0274 |
Bitewings - four radiographic images |
525 |
521 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,301 |
712 |
$5K |
| D9430 |
|
110 |
106 |
$3K |
| D1110 |
Prophylaxis - adult |
38 |
38 |
$3K |
| D1310 |
|
90 |
89 |
$3K |
| D9993 |
|
40 |
38 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
27 |
$288.00 |