| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
96 |
94 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
55 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
85 |
84 |
$2K |
| D1120 |
Prophylaxis - child |
57 |
57 |
$2K |
| D1206 |
Topical application of fluoride varnish |
87 |
86 |
$2K |
| D0274 |
Bitewings - four radiographic images |
44 |
43 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
59 |
58 |
$1K |
| D0272 |
Bitewings - two radiographic images |
31 |
31 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$597.35 |
| D0603 |
|
49 |
49 |
$0.06 |
| D0602 |
|
29 |
28 |
$0.05 |