| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,274 |
1,274 |
$48K |
| D1110 |
Prophylaxis - adult |
453 |
453 |
$23K |
| D0272 |
Bitewings - two radiographic images |
759 |
759 |
$20K |
| D1120 |
Prophylaxis - child |
538 |
538 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,012 |
1,004 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
961 |
961 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
705 |
652 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
127 |
127 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
70 |
$3K |
| D1351 |
Sealant - per tooth |
57 |
12 |
$2K |