| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
784 |
770 |
$49K |
| D1110 |
Prophylaxis - adult |
539 |
529 |
$11K |
| D1120 |
Prophylaxis - child |
338 |
332 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
78 |
$6K |
| D0274 |
Bitewings - four radiographic images |
180 |
179 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$2K |
| D0330 |
Panoramic radiographic image |
105 |
104 |
$1K |
| D0272 |
Bitewings - two radiographic images |
592 |
582 |
$328.11 |
| D1351 |
Sealant - per tooth |
260 |
62 |
$154.56 |
| D0220 |
Intraoral - periapical first radiographic image |
749 |
734 |
$110.26 |
| D0230 |
Intraoral - periapical each additional radiographic image |
718 |
682 |
$95.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
895 |
879 |
$16.35 |
| D1330 |
|
902 |
886 |
$0.00 |