| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,154 |
1,146 |
$123K |
| D0272 |
Bitewings - two radiographic images |
818 |
811 |
$21K |
| D1120 |
Prophylaxis - child |
1,290 |
1,282 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,048 |
1,038 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,196 |
973 |
$12K |
| D1206 |
Topical application of fluoride varnish |
1,264 |
1,264 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
48 |
$5K |
| D1351 |
Sealant - per tooth |
177 |
31 |
$5K |
| D0274 |
Bitewings - four radiographic images |
181 |
180 |
$3K |
| D0330 |
Panoramic radiographic image |
44 |
44 |
$1K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$59.44 |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
38 |
$0.00 |