| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
715 |
690 |
$17K |
| D1110 |
Prophylaxis - adult |
363 |
353 |
$16K |
| D1120 |
Prophylaxis - child |
379 |
368 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
122 |
122 |
$9K |
| D1206 |
Topical application of fluoride varnish |
452 |
438 |
$9K |
| D0272 |
Bitewings - two radiographic images |
154 |
149 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
70 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
156 |
146 |
$2K |
| D1351 |
Sealant - per tooth |
68 |
17 |
$2K |
| D0330 |
Panoramic radiographic image |
58 |
57 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
55 |
52 |
$541.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
29 |
$531.02 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$342.00 |