| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,519 |
1,519 |
$82K |
| D0120 |
Periodic oral evaluation - established patient |
2,007 |
2,005 |
$54K |
| D1120 |
Prophylaxis - child |
1,092 |
1,089 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,155 |
1,155 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,239 |
1,238 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,035 |
1,034 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
649 |
649 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,191 |
1,189 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
189 |
189 |
$10K |
| D0272 |
Bitewings - two radiographic images |
443 |
442 |
$7K |
| D1206 |
Topical application of fluoride varnish |
90 |
90 |
$2K |
| D1351 |
Sealant - per tooth |
55 |
14 |
$2K |
| D1999 |
|
15 |
14 |
$0.00 |