| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
837 |
813 |
$34K |
| D1120 |
Prophylaxis - child |
749 |
731 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
329 |
303 |
$13K |
| D1206 |
Topical application of fluoride varnish |
550 |
544 |
$12K |
| D0330 |
Panoramic radiographic image |
207 |
205 |
$9K |
| D1351 |
Sealant - per tooth |
330 |
105 |
$9K |
| D0274 |
Bitewings - four radiographic images |
204 |
198 |
$5K |
| D0272 |
Bitewings - two radiographic images |
120 |
120 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
54 |
52 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
108 |
95 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
67 |
67 |
$926.00 |
| D0350 |
|
18 |
18 |
$445.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
33 |
12 |
$254.86 |