| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
969 |
943 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,154 |
1,107 |
$22K |
| D1206 |
Topical application of fluoride varnish |
620 |
606 |
$8K |
| D1110 |
Prophylaxis - adult |
206 |
191 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
265 |
261 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
270 |
262 |
$4K |
| D0330 |
Panoramic radiographic image |
74 |
70 |
$2K |
| D0274 |
Bitewings - four radiographic images |
80 |
79 |
$2K |
| D0272 |
Bitewings - two radiographic images |
60 |
59 |
$967.96 |
| D1330 |
|
118 |
107 |
$585.20 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$514.80 |
| D9986 |
|
93 |
73 |
$15.00 |
| D1310 |
|
18 |
14 |
$0.00 |