| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
552 |
550 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
447 |
435 |
$25K |
| D0330 |
Panoramic radiographic image |
478 |
473 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
582 |
565 |
$13K |
| D0274 |
Bitewings - four radiographic images |
536 |
531 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
375 |
369 |
$11K |
| D1120 |
Prophylaxis - child |
255 |
243 |
$11K |
| D2750 |
|
16 |
14 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
175 |
169 |
$2K |
| D1330 |
|
217 |
211 |
$1K |
| D2950 |
|
16 |
14 |
$1K |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$420.64 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$180.00 |