| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
475 |
475 |
$29K |
| D1120 |
Prophylaxis - child |
523 |
520 |
$14K |
| D1206 |
Topical application of fluoride varnish |
907 |
902 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
95 |
95 |
$6K |
| D1351 |
Sealant - per tooth |
319 |
92 |
$5K |
| D1110 |
Prophylaxis - adult |
81 |
79 |
$5K |
| D1330 |
|
915 |
910 |
$2K |
| D9996 |
|
189 |
189 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
24 |
24 |
$600.00 |
| D0274 |
Bitewings - four radiographic images |
42 |
42 |
$581.44 |
| D1354 |
|
36 |
12 |
$442.80 |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
56 |
$247.68 |
| D0190 |
|
38 |
38 |
$99.84 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$99.76 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
16 |
$0.00 |