| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
632 |
586 |
$14K |
| D1110 |
Prophylaxis - adult |
466 |
440 |
$14K |
| D1206 |
Topical application of fluoride varnish |
1,015 |
946 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
824 |
767 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
163 |
153 |
$4K |
| D0274 |
Bitewings - four radiographic images |
119 |
117 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
185 |
166 |
$2K |
| D0272 |
Bitewings - two radiographic images |
54 |
50 |
$928.06 |
| D0330 |
Panoramic radiographic image |
16 |
14 |
$460.50 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
15 |
$341.09 |
| D1999 |
|
37 |
26 |
$0.00 |