| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
460 |
460 |
$14K |
| D1120 |
Prophylaxis - child |
248 |
248 |
$11K |
| D1206 |
Topical application of fluoride varnish |
299 |
299 |
$9K |
| D1110 |
Prophylaxis - adult |
204 |
204 |
$9K |
| D1351 |
Sealant - per tooth |
267 |
45 |
$5K |
| D0274 |
Bitewings - four radiographic images |
184 |
184 |
$2K |
| D0272 |
Bitewings - two radiographic images |
207 |
207 |
$2K |
| D0330 |
Panoramic radiographic image |
49 |
49 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
303 |
285 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
40 |
40 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
214 |
211 |
$942.00 |
| D0140 |
Limited oral evaluation - problem focused |
71 |
69 |
$847.00 |