| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
423 |
420 |
$9K |
| D1120 |
Prophylaxis - child |
278 |
275 |
$9K |
| D1110 |
Prophylaxis - adult |
143 |
143 |
$9K |
| D0330 |
Panoramic radiographic image |
99 |
99 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
250 |
249 |
$7K |
| D0272 |
Bitewings - two radiographic images |
223 |
222 |
$5K |
| D0274 |
Bitewings - four radiographic images |
96 |
96 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
108 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
77 |
77 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$482.00 |