| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
133 |
115 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
71 |
62 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
98 |
$2K |
| D0274 |
Bitewings - four radiographic images |
73 |
64 |
$1K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$940.25 |
| D0120 |
Periodic oral evaluation - established patient |
60 |
56 |
$771.48 |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
19 |
$244.91 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$227.60 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$218.20 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$180.46 |
| D0220 |
Intraoral - periapical first radiographic image |
18 |
16 |
$122.34 |