| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
331 |
314 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
110 |
110 |
$5K |
| D1110 |
Prophylaxis - adult |
116 |
116 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
146 |
146 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
98 |
98 |
$2K |
| D1120 |
Prophylaxis - child |
65 |
65 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
76 |
76 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
138 |
136 |
$722.88 |
| D0330 |
Panoramic radiographic image |
21 |
21 |
$360.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$228.76 |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
14 |
$142.80 |