| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
543 |
514 |
$17K |
| D0330 |
Panoramic radiographic image |
228 |
208 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
461 |
446 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
162 |
146 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
226 |
212 |
$3K |
| D0274 |
Bitewings - four radiographic images |
151 |
144 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
100 |
86 |
$2K |
| D1120 |
Prophylaxis - child |
42 |
39 |
$840.00 |
| D0220 |
Intraoral - periapical first radiographic image |
88 |
82 |
$350.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
12 |
$130.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$100.00 |