| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
878 |
863 |
$29K |
| D1206 |
Topical application of fluoride varnish |
771 |
759 |
$25K |
| D1120 |
Prophylaxis - child |
657 |
647 |
$23K |
| D1110 |
Prophylaxis - adult |
221 |
219 |
$10K |
| D0274 |
Bitewings - four radiographic images |
215 |
213 |
$7K |
| D0330 |
Panoramic radiographic image |
91 |
90 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
131 |
130 |
$5K |
| D1351 |
Sealant - per tooth |
150 |
39 |
$4K |
| D0272 |
Bitewings - two radiographic images |
67 |
65 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
36 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$195.00 |