| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
448 |
440 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
293 |
290 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
579 |
560 |
$12K |
| D1206 |
Topical application of fluoride varnish |
864 |
854 |
$11K |
| D1120 |
Prophylaxis - child |
331 |
326 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,129 |
722 |
$9K |
| D0272 |
Bitewings - two radiographic images |
580 |
569 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
132 |
127 |
$6K |
| D2140 |
|
22 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
60 |
60 |
$900.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
115 |
109 |
$656.50 |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
38 |
$430.00 |