| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
703 |
703 |
$18K |
| D1120 |
Prophylaxis - child |
327 |
327 |
$15K |
| D1206 |
Topical application of fluoride varnish |
384 |
384 |
$12K |
| D1110 |
Prophylaxis - adult |
230 |
230 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
161 |
160 |
$7K |
| D0330 |
Panoramic radiographic image |
106 |
106 |
$4K |
| D0274 |
Bitewings - four radiographic images |
252 |
252 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
85 |
85 |
$2K |
| D1351 |
Sealant - per tooth |
91 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
70 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
312 |
301 |
$2K |
| D0272 |
Bitewings - two radiographic images |
50 |
50 |
$500.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
74 |
73 |
$258.00 |
| D0601 |
|
14 |
14 |
$140.00 |