| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
443 |
429 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
525 |
514 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
291 |
280 |
$7K |
| D0330 |
Panoramic radiographic image |
96 |
96 |
$4K |
| D1206 |
Topical application of fluoride varnish |
87 |
87 |
$3K |
| D1120 |
Prophylaxis - child |
52 |
52 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
251 |
248 |
$1K |
| D0274 |
Bitewings - four radiographic images |
75 |
74 |
$882.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$544.50 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$540.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
104 |
103 |
$381.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$120.00 |