| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
303 |
286 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
192 |
168 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
70 |
52 |
$5K |
| D1206 |
Topical application of fluoride varnish |
216 |
199 |
$4K |
| D0274 |
Bitewings - four radiographic images |
129 |
127 |
$4K |
| D0330 |
Panoramic radiographic image |
61 |
61 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
131 |
120 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
84 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
54 |
54 |
$807.72 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$336.03 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$335.39 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$83.82 |