| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
427 |
427 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
512 |
512 |
$11K |
| D1206 |
Topical application of fluoride varnish |
280 |
251 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
129 |
129 |
$6K |
| D0274 |
Bitewings - four radiographic images |
456 |
455 |
$5K |
| D1120 |
Prophylaxis - child |
180 |
180 |
$5K |
| D1999 |
|
265 |
257 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
120 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
95 |
92 |
$2K |
| D0330 |
Panoramic radiographic image |
243 |
243 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
144 |
139 |
$721.25 |
| D0230 |
Intraoral - periapical each additional radiographic image |
60 |
24 |
$249.90 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$67.69 |