| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,325 |
1,305 |
$39K |
| D1110 |
Prophylaxis - adult |
545 |
542 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
825 |
808 |
$19K |
| D1120 |
Prophylaxis - child |
430 |
428 |
$19K |
| D1206 |
Topical application of fluoride varnish |
577 |
572 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,304 |
1,280 |
$13K |
| D0274 |
Bitewings - four radiographic images |
535 |
531 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
145 |
145 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,082 |
1,068 |
$7K |
| D1351 |
Sealant - per tooth |
103 |
14 |
$3K |
| D0330 |
Panoramic radiographic image |
66 |
66 |
$3K |
| D1330 |
|
429 |
421 |
$3K |
| D0272 |
Bitewings - two radiographic images |
87 |
84 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
21 |
21 |
$1K |