| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
477 |
448 |
$12K |
| D1120 |
Prophylaxis - child |
303 |
289 |
$9K |
| D1110 |
Prophylaxis - adult |
202 |
181 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
625 |
588 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
724 |
662 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
756 |
597 |
$6K |
| D0274 |
Bitewings - four radiographic images |
198 |
177 |
$5K |
| D1351 |
Sealant - per tooth |
111 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
77 |
76 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$459.16 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$415.80 |
| D0602 |
|
463 |
435 |
$0.00 |
| D0603 |
|
46 |
43 |
$0.00 |
| D1330 |
|
14 |
14 |
$0.00 |