| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
706 |
686 |
$22K |
| D1110 |
Prophylaxis - adult |
361 |
360 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
517 |
515 |
$13K |
| D0330 |
Panoramic radiographic image |
164 |
164 |
$7K |
| D1120 |
Prophylaxis - child |
125 |
125 |
$6K |
| D0274 |
Bitewings - four radiographic images |
462 |
462 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
160 |
160 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
38 |
$2K |
| D1351 |
Sealant - per tooth |
80 |
13 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
39 |
39 |
$975.00 |
| D0220 |
Intraoral - periapical first radiographic image |
240 |
238 |
$893.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
32 |
$121.00 |