| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,641 |
1,605 |
$41K |
| D1206 |
Topical application of fluoride varnish |
1,680 |
1,643 |
$27K |
| D4355 |
|
264 |
252 |
$17K |
| D1110 |
Prophylaxis - adult |
445 |
423 |
$16K |
| D1120 |
Prophylaxis - child |
535 |
532 |
$15K |
| D0274 |
Bitewings - four radiographic images |
225 |
216 |
$7K |
| D0330 |
Panoramic radiographic image |
68 |
64 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
12 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
56 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
99 |
95 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
87 |
17 |
$989.42 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$556.80 |