| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,807 |
1,807 |
$49K |
| D1120 |
Prophylaxis - child |
1,221 |
1,221 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,763 |
1,763 |
$42K |
| D1110 |
Prophylaxis - adult |
562 |
562 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,734 |
965 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,367 |
1,341 |
$22K |
| D1351 |
Sealant - per tooth |
699 |
109 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
122 |
122 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
181 |
181 |
$8K |
| D0274 |
Bitewings - four radiographic images |
210 |
210 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$610.82 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$325.00 |