| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
612 |
599 |
$29K |
| D1120 |
Prophylaxis - child |
530 |
525 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
839 |
822 |
$15K |
| D0274 |
Bitewings - four radiographic images |
424 |
418 |
$12K |
| D1206 |
Topical application of fluoride varnish |
770 |
764 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
293 |
290 |
$9K |
| D0330 |
Panoramic radiographic image |
117 |
117 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
109 |
103 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
117 |
113 |
$873.36 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
27 |
$166.32 |
| D9986 |
|
15 |
15 |
$0.00 |