| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,223 |
1,222 |
$27K |
| D1110 |
Prophylaxis - adult |
745 |
745 |
$24K |
| D1206 |
Topical application of fluoride varnish |
565 |
528 |
$12K |
| D1120 |
Prophylaxis - child |
307 |
306 |
$8K |
| D0274 |
Bitewings - four radiographic images |
342 |
342 |
$5K |
| D1999 |
|
268 |
258 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
307 |
303 |
$1K |
| D1351 |
Sealant - per tooth |
43 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
265 |
102 |
$973.50 |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$780.30 |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$650.76 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
22 |
22 |
$493.68 |
| D0330 |
Panoramic radiographic image |
58 |
58 |
$295.22 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$265.20 |