| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,895 |
2,893 |
$151K |
| D1120 |
Prophylaxis - child |
3,022 |
3,018 |
$107K |
| D2140 |
|
605 |
296 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,200 |
3,197 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,490 |
1,489 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,680 |
3,374 |
$26K |
| D1351 |
Sealant - per tooth |
729 |
135 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,516 |
1,280 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,442 |
1,441 |
$17K |
| D9430 |
|
90 |
90 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$3K |