| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
250 |
246 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
322 |
313 |
$11K |
| D0274 |
Bitewings - four radiographic images |
252 |
245 |
$9K |
| D0330 |
Panoramic radiographic image |
155 |
147 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
288 |
170 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
94 |
89 |
$4K |
| D1320 |
|
112 |
105 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$765.00 |
| D1330 |
|
95 |
88 |
$682.64 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$511.92 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$180.00 |