| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
301 |
299 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
307 |
300 |
$8K |
| D1120 |
Prophylaxis - child |
216 |
211 |
$4K |
| D1110 |
Prophylaxis - adult |
87 |
87 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
435 |
426 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
336 |
334 |
$81.00 |
| D0220 |
Intraoral - periapical first radiographic image |
467 |
456 |
$80.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
433 |
425 |
$72.42 |
| D0272 |
Bitewings - two radiographic images |
95 |
95 |
$21.00 |
| D1330 |
|
354 |
349 |
$3.00 |
| D1351 |
Sealant - per tooth |
54 |
13 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
47 |
47 |
$0.00 |