| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
289 |
289 |
$5K |
| D0274 |
Bitewings - four radiographic images |
153 |
153 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
142 |
142 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
95 |
95 |
$3K |
| D1110 |
Prophylaxis - adult |
54 |
54 |
$2K |
| D1120 |
Prophylaxis - child |
44 |
44 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$584.22 |
| D0120 |
Periodic oral evaluation - established patient |
25 |
25 |
$490.06 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
12 |
$144.84 |