| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
452 |
430 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
615 |
584 |
$16K |
| D1206 |
Topical application of fluoride varnish |
521 |
495 |
$11K |
| D1110 |
Prophylaxis - adult |
119 |
113 |
$6K |
| D0272 |
Bitewings - two radiographic images |
196 |
183 |
$6K |
| D0330 |
Panoramic radiographic image |
78 |
75 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
225 |
223 |
$3K |
| D0274 |
Bitewings - four radiographic images |
92 |
90 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
202 |
171 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
60 |
60 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$940.06 |
| D0603 |
|
111 |
111 |
$0.06 |
| D0601 |
|
28 |
28 |
$0.01 |