| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,687 |
1,676 |
$48K |
| D1110 |
Prophylaxis - adult |
748 |
745 |
$41K |
| D1120 |
Prophylaxis - child |
933 |
924 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,770 |
1,761 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
875 |
611 |
$10K |
| D0145 |
Oral evaluation for a patient under three years of age |
62 |
62 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
691 |
679 |
$8K |
| D0274 |
Bitewings - four radiographic images |
238 |
236 |
$8K |
| D1351 |
Sealant - per tooth |
56 |
17 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$423.84 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$350.70 |
| D0601 |
|
612 |
612 |
$0.00 |
| D0603 |
|
777 |
776 |
$0.00 |
| D0602 |
|
324 |
324 |
$0.00 |