| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
784 |
779 |
$45K |
| D0274 |
Bitewings - four radiographic images |
800 |
797 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,121 |
1,107 |
$28K |
| D0330 |
Panoramic radiographic image |
208 |
204 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
191 |
191 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
285 |
284 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
355 |
341 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
111 |
105 |
$4K |
| D1120 |
Prophylaxis - child |
79 |
79 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
225 |
196 |
$3K |
| D1206 |
Topical application of fluoride varnish |
80 |
79 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$962.00 |