| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
754 |
632 |
$25K |
| D1120 |
Prophylaxis - child |
597 |
507 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
820 |
697 |
$18K |
| D0274 |
Bitewings - four radiographic images |
455 |
379 |
$9K |
| D0330 |
Panoramic radiographic image |
249 |
204 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
598 |
509 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
427 |
364 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
50 |
$395.40 |
| D1206 |
Topical application of fluoride varnish |
30 |
24 |
$279.00 |
| D0272 |
Bitewings - two radiographic images |
16 |
13 |
$248.43 |
| D1999 |
|
484 |
425 |
$0.00 |
| D9986 |
|
82 |
64 |
$0.00 |