| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
401 |
394 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
539 |
527 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
478 |
466 |
$3K |
| D1330 |
|
155 |
153 |
$2K |
| D1110 |
Prophylaxis - adult |
181 |
176 |
$2K |
| D0330 |
Panoramic radiographic image |
44 |
43 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$934.77 |
| D0272 |
Bitewings - two radiographic images |
175 |
170 |
$789.92 |
| D0220 |
Intraoral - periapical first radiographic image |
279 |
266 |
$695.18 |
| D0601 |
|
249 |
245 |
$646.42 |
| D0230 |
Intraoral - periapical each additional radiographic image |
270 |
249 |
$519.16 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$88.40 |
| D0602 |
|
12 |
12 |
$0.00 |