| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,029 |
1,025 |
$45K |
| D9110 |
|
536 |
520 |
$33K |
| D1120 |
Prophylaxis - child |
700 |
698 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,694 |
1,527 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,272 |
1,395 |
$18K |
| D1110 |
Prophylaxis - adult |
168 |
167 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,284 |
1,280 |
$14K |
| D0274 |
Bitewings - four radiographic images |
540 |
538 |
$11K |
| D0350 |
|
555 |
267 |
$6K |
| D2920 |
|
105 |
67 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
52 |
52 |
$2K |
| D2330 |
|
21 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$2K |
| D1351 |
Sealant - per tooth |
40 |
12 |
$858.00 |
| D9430 |
|
15 |
15 |
$480.00 |