| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
442 |
441 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
708 |
704 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
327 |
326 |
$18K |
| D4341 |
|
196 |
75 |
$16K |
| D0274 |
Bitewings - four radiographic images |
614 |
611 |
$15K |
| D1206 |
Topical application of fluoride varnish |
516 |
516 |
$13K |
| D0330 |
Panoramic radiographic image |
277 |
276 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
322 |
321 |
$7K |
| D1120 |
Prophylaxis - child |
153 |
153 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
470 |
465 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
298 |
296 |
$4K |
| D1330 |
|
150 |
149 |
$894.00 |