| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
360 |
349 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
242 |
236 |
$7K |
| D0330 |
Panoramic radiographic image |
178 |
176 |
$6K |
| D0274 |
Bitewings - four radiographic images |
368 |
357 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
160 |
155 |
$3K |
| D1206 |
Topical application of fluoride varnish |
56 |
56 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$628.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
27 |
$621.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$508.44 |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$505.00 |
| D1330 |
|
25 |
25 |
$150.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$79.60 |