| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
419 |
407 |
$18K |
| D0330 |
Panoramic radiographic image |
213 |
210 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
242 |
238 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
173 |
164 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
104 |
$3K |
| D1120 |
Prophylaxis - child |
137 |
137 |
$3K |
| D0272 |
Bitewings - two radiographic images |
175 |
170 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
206 |
205 |
$2K |
| D1206 |
Topical application of fluoride varnish |
114 |
114 |
$2K |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$990.48 |
| D1354 |
|
51 |
13 |
$803.25 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
15 |
$195.59 |