| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,660 |
1,638 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,107 |
1,095 |
$26K |
| D1110 |
Prophylaxis - adult |
659 |
655 |
$24K |
| D1999 |
|
1,707 |
1,555 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
674 |
618 |
$14K |
| D1120 |
Prophylaxis - child |
464 |
463 |
$13K |
| D0274 |
Bitewings - four radiographic images |
524 |
518 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
206 |
206 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
85 |
85 |
$510.65 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$210.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
36 |
13 |
$174.90 |