| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
496 |
495 |
$22K |
| D1206 |
Topical application of fluoride varnish |
693 |
691 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
415 |
395 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
430 |
430 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
882 |
868 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
80 |
80 |
$4K |
| D1120 |
Prophylaxis - child |
66 |
66 |
$3K |
| D0274 |
Bitewings - four radiographic images |
244 |
244 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
413 |
411 |
$2K |
| D4355 |
|
14 |
14 |
$2K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$1K |
| D0272 |
Bitewings - two radiographic images |
43 |
43 |
$430.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$300.00 |