| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
568 |
524 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
755 |
698 |
$15K |
| D0274 |
Bitewings - four radiographic images |
57 |
50 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
34 |
33 |
$980.00 |
| D1120 |
Prophylaxis - child |
27 |
26 |
$866.50 |
| D0330 |
Panoramic radiographic image |
31 |
26 |
$795.40 |
| D0272 |
Bitewings - two radiographic images |
27 |
25 |
$554.64 |
| D1206 |
Topical application of fluoride varnish |
27 |
26 |
$491.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$216.24 |