| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,255 |
1,247 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,033 |
1,030 |
$26K |
| D2750 |
|
29 |
24 |
$16K |
| D1206 |
Topical application of fluoride varnish |
385 |
385 |
$11K |
| D0274 |
Bitewings - four radiographic images |
628 |
626 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
210 |
210 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
650 |
640 |
$3K |
| D1120 |
Prophylaxis - child |
66 |
66 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
442 |
438 |
$3K |
| D0330 |
Panoramic radiographic image |
53 |
53 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$1K |