| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
779 |
771 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,698 |
1,795 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
473 |
472 |
$28K |
| D1110 |
Prophylaxis - adult |
319 |
318 |
$27K |
| D9430 |
|
617 |
562 |
$19K |
| D1120 |
Prophylaxis - child |
521 |
513 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,271 |
1,157 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,167 |
1,157 |
$14K |
| D0274 |
Bitewings - four radiographic images |
233 |
228 |
$4K |
| D4341 |
|
91 |
24 |
$4K |
| D1351 |
Sealant - per tooth |
121 |
27 |
$3K |
| D9110 |
|
46 |
43 |
$3K |
| D0272 |
Bitewings - two radiographic images |
127 |
127 |
$1K |
| D1999 |
|
36 |
36 |
$80.50 |