| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,174 |
1,098 |
$48K |
| D0274 |
Bitewings - four radiographic images |
1,715 |
1,632 |
$38K |
| D1206 |
Topical application of fluoride varnish |
1,173 |
1,097 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
1,658 |
1,562 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
636 |
606 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,327 |
2,043 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
475 |
453 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
431 |
409 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
146 |
125 |
$7K |
| D0160 |
|
85 |
68 |
$2K |
| D1351 |
Sealant - per tooth |
71 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
71 |
66 |
$1K |
| D1999 |
|
14 |
14 |
$210.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
14 |
14 |
$140.00 |