| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
297 |
292 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
415 |
413 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
191 |
188 |
$5K |
| D0330 |
Panoramic radiographic image |
62 |
62 |
$3K |
| D1206 |
Topical application of fluoride varnish |
81 |
81 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
44 |
41 |
$2K |
| D1120 |
Prophylaxis - child |
46 |
45 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$330.00 |
| D0274 |
Bitewings - four radiographic images |
30 |
26 |
$300.00 |
| D0220 |
Intraoral - periapical first radiographic image |
59 |
55 |
$182.00 |
| D0603 |
|
12 |
12 |
$90.00 |