| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,160 |
2,151 |
$126K |
| D1110 |
Prophylaxis - adult |
848 |
844 |
$75K |
| D1120 |
Prophylaxis - child |
1,128 |
1,120 |
$47K |
| D1206 |
Topical application of fluoride varnish |
2,829 |
2,812 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
490 |
484 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,862 |
1,777 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
696 |
671 |
$8K |
| D1351 |
Sealant - per tooth |
167 |
42 |
$6K |
| D0350 |
|
627 |
405 |
$5K |
| D0272 |
Bitewings - two radiographic images |
306 |
306 |
$4K |
| D0274 |
Bitewings - four radiographic images |
48 |
48 |
$1K |
| D9110 |
|
14 |
14 |
$882.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$94.00 |
| D0270 |
|
13 |
12 |
$65.00 |
| D1999 |
|
16 |
15 |
$0.00 |