| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
511 |
508 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
728 |
726 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
182 |
173 |
$8K |
| D0274 |
Bitewings - four radiographic images |
599 |
597 |
$7K |
| D1120 |
Prophylaxis - child |
134 |
134 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
866 |
853 |
$4K |
| D0330 |
Panoramic radiographic image |
97 |
97 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
179 |
179 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
717 |
711 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
47 |
$1K |
| D0602 |
|
123 |
123 |
$780.00 |