| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
787 |
759 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
974 |
936 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
690 |
665 |
$16K |
| D0274 |
Bitewings - four radiographic images |
638 |
611 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
796 |
750 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
715 |
678 |
$6K |
| D1120 |
Prophylaxis - child |
88 |
85 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
88 |
85 |
$2K |
| D0330 |
Panoramic radiographic image |
99 |
95 |
$2K |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$370.97 |
| D1999 |
|
20 |
15 |
$0.00 |