| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
50 |
49 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
88 |
86 |
$2K |
| D1120 |
Prophylaxis - child |
48 |
47 |
$2K |
| D0274 |
Bitewings - four radiographic images |
54 |
52 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
104 |
102 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
116 |
112 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
135 |
109 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$737.39 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$423.84 |
| D0601 |
|
47 |
45 |
$0.00 |
| D0603 |
|
85 |
80 |
$0.00 |