| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
308 |
306 |
$12K |
| D1206 |
Topical application of fluoride varnish |
451 |
448 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
227 |
226 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
623 |
600 |
$6K |
| D0274 |
Bitewings - four radiographic images |
218 |
218 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
119 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
116 |
116 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
360 |
327 |
$2K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$989.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$462.00 |
| D0191 |
|
12 |
12 |
$94.50 |