| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
2,359 |
2,301 |
$57K |
| D1110 |
Prophylaxis - adult |
1,322 |
1,318 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,759 |
1,753 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,207 |
1,204 |
$19K |
| D1999 |
|
1,571 |
1,459 |
$16K |
| D1120 |
Prophylaxis - child |
377 |
377 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,586 |
1,561 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,538 |
1,355 |
$6K |
| D1351 |
Sealant - per tooth |
207 |
39 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
187 |
176 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
79 |
79 |
$4K |
| D0330 |
Panoramic radiographic image |
126 |
125 |
$853.50 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$274.68 |