| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
694 |
694 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,130 |
1,130 |
$25K |
| D0274 |
Bitewings - four radiographic images |
740 |
740 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,111 |
1,111 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,226 |
1,205 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,021 |
1,002 |
$10K |
| D1120 |
Prophylaxis - child |
293 |
293 |
$10K |
| D2394 |
|
30 |
12 |
$4K |
| D0330 |
Panoramic radiographic image |
56 |
56 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
80 |
64 |
$3K |
| D0272 |
Bitewings - two radiographic images |
122 |
122 |
$2K |
| D0240 |
|
51 |
26 |
$858.26 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$688.50 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$500.50 |