| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,007 |
988 |
$28K |
| D1120 |
Prophylaxis - child |
769 |
750 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,650 |
1,181 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,319 |
1,285 |
$15K |
| D1206 |
Topical application of fluoride varnish |
922 |
906 |
$13K |
| D1351 |
Sealant - per tooth |
457 |
80 |
$13K |
| D0350 |
|
594 |
573 |
$9K |
| D0274 |
Bitewings - four radiographic images |
249 |
247 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
58 |
58 |
$8K |
| D0272 |
Bitewings - two radiographic images |
360 |
348 |
$8K |
| D1110 |
Prophylaxis - adult |
130 |
130 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
59 |
59 |
$852.60 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$847.68 |
| D0603 |
|
953 |
939 |
$0.00 |
| D0602 |
|
460 |
455 |
$0.00 |